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2. 
3. NBPD FINANCIAL FRAUD PACKET
   This form is intended to be filled out by those that are using NBPD's Online Police Report system to file a financial crimes or fraud report. In order to help investigators with your case, please fill out the information accurately and completely using as much specific information as possible.
7. First Name*
8. Middle Name
9. Last Name*
10. Suffix (Jr., Sr., etc)
14. Date of Birth*
    Date of Birth
16. Drivers License or State ID #*
17. State Issued*
19. Home Phone #
20. Work Phone #
21. Cell or Mobile Phone #
23. Social Security #*
24. Email Address
28. Home Address*
30. Apt. or Unit # (if applicable)
32. City*
33. State*
34. Zip Code*
36. Was your home address different at the time of the crime?

    1. Yes
    2. No
38. Home Address at Time of Crime
42. Is the person listed above the victim of the financial crime?*

    1. Yes
    2. No
44. Victim Name
45. Victim Date of Birth
    Victim Date of Birth
47. Victim Phone #
48. Victim Email Address
50. Victim Physical Address
54. Financial Fraud Questions*

    To the best of your knowledge, what type of crime has been committed against you? (Check all that apply)

    1. My checks were lost or stolen and my signature was forged.
    2. My checking account number was used on fraudulent/counterfeit checks.
    3. Checks that I previously wrote have been altered and cashed.
    4. My credit or debit card was lost or stolen and used without my permission.
    5. My debit or credit card number was used without my permission (but I still have my card).
    6. My information was used to open utility accounts (ex: water, cable, electricity, phone service).
    7. My information was used to open one or more credit card accounts.
    8. My information was used to open one or more bank accounts.
    9. My information was used to take out an unauthorized loan.
    10. My signature was forged on a government or financial document (ex: loan application or car title).
    11. My information was used by someone other than me to obtain employment.
    12. Unauthorized withdrawals were made from my bank account.
    13. Gift cards were lost or stolen.
    14. Other
56. Other Type of Crime
    You selected Other from the previous list. Please describe the type of crime.
60. Tell Us About the Crime*
    Please include the date you first became aware of the crime, when the fraudulent activity began, and how you became aware of the crime. Please be as specific as possible.
62. Supporting Documentation
    PLEASE NOTE: You will be asked to provide supporting documentation for each fraudulent act. This could include bank statements, copies of checks, copies of bills, copies of applications, proof of accounts from collection agencies, or copies of credit reports. This information can be uploaded to the actual police report using the Online Police Report system.
64. Documents Stolen or Fraudulently Used*
    Please list all credit cards, bank cards, checks, documents, or forms of identification that were stolen, obtained in your name, or fraudulently used. Be sure to include account numbers, ID numbers, check numbers, and other specific information.
68. Compromised Documents or Information*

    To help assist us with determining how your information may have been compromised, please check any of the following that may be applicable:

    1. I carry my Social Security Card in my wallet or purse.
    2. I carry bank account passwords or PIN's in my wallet or purse.
    3. My wallet or purse was stolen.
    4. My check book was stolen.
    5. My home or vehicle was burglarized.
    6. I gave my password or pin to someone else.
    7. I did not receive a bill as usual (ex: Credit card bill failed to come in the mail).
    8. I mailed one or more checks that were not cashed by the payee listed on the check.
    9. My address was changed at the post office without my knowledge.
    10. Credit card bills, credit card offers, or credit card convenience checks were thrown away without being shredded.
    11. Documentation containing my personal information was thrown away without being shredded.
    12. Service or cleaning vendors were in my home.
    13. My incoming or outgoing mail was stolen.
    14. I gave my personal or financial information after it was requested in an email.
    15. I gave my personal or financial information over the phone when I did not initiate the phone call.
    16. I responded to an online job posting.
    17. Other
70. Password or PIN Given to Other Person
    You indicated that you gave your password or PIN to someone else. Please give us their name and any contact information (ex: phone number) that you have for them.
72. Service or Cleaning Vendors
    You indicated that service or cleaning vendors were in your home. Please provide us with the name and contact information (ex: phone numbers) for each vendor that was in your home when you believe your information was compromised.
74. Incoming or Outgoing Mail Stolen
    Incoming or Outgoing Mail Stolen Start Date

    —

    Incoming or Outgoing Mail Stolen End Date
    You indicated that your incoming or outgoing mail was stolen. Please give us the date range when your mail was stolen.
76. Other
    You indicated that your information may have been compromised in a way that was not listed here. Please tell us how you believe your information was compromised.
80. Do you have information about a possible suspect?

    1. Yes
    2. No
82. Suspect Name
83. Suspect Nickname
85. Suspect Date of Birth
    Suspect Date of Birth
86. Suspect Gender

    1. Male
    2. Female
87. Suspect Race/Ethnicity
    -- Select One --American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhite
89. Suspect Phone #
90. Suspect Email Address
92. Suspect Physical Address
94. Suspect's Relation to You (if any)
98. Are there any witnesses to this crime?

    1. Yes
    2. No
100. Witness Information
     Please provide the full name and contact information for each witness.
104. I have previously reported this crime to another law enforcement agency.*

     1. Yes
     2. No
106. Law Enforcement Agency Information
     Please provide the name of the law enforcement agency, the name of the person that took the report, their contact phone number, and a case number or report number.
110. Did you authorize anyone to use your name or personal information to seek employment, money, credit, loans, goods, or services?*

     1. Yes
     2. No
112. Did you receive any benefit, money, goods, or services as a result of the crime committed against you?*

     1. Yes
     2. No
114. I am willing to assist in the prosecution of the person(s) who committed this crime against me, even if the suspect is related or known to me.*

     1. Yes
     2. No
116. I authorize the release of any information to law enforcement for the purpose of assisting in the investigation and prosecution of the person(s) who committed this fraud.*

     1. Yes
     2. No
120. Additional Information
     Please provide us with any additional information that may be helpful in the investigation of your financial crime.
122. Additional Information May Be Needed
     PLEASE NOTE: This form is designed to give investigators a preliminary look at the crime you are reporting. Additional information, including detailed financial records, bank statements, and copies of documents like checks, bills, applications, and/or credit reports may be required.
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124. 1. Receive an email copy of this form.
125. Email address

     This field is not part of the form submission.

126. Submit

* indicates a required field