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COTTAGE GROVE POLICE DEPARTMENT FINANCIAL CRIME PACKET (City of Cottage Grove)

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COTTAGE GROVE POLICE DEPARTMENT
FINANCIAL CRIME PACKET
 REPORTING IDENTITY THEFT AND FINANCIAL
TRANSACTION CARD FRAUD
The information requested in this packet is needed for the effective investigation and
prosecution of financial crimes. It is important that you as the reporting party provide
us with the information necessary to investigate. Please contact your bank and/or
creditor and request the location(s), date(s), and time(s) of the unauthorized usage.
Please answer the following questions to help us better evaluate the situation:
Yes No Circumstances of your case

My credit, debit, or other type of financial card was lost or stolen.
Where?

My credit, debit, or other type of financial card was presented to a merchant without my
permission. Where?

My credit, debit, or other type of financial card was used to make an unauthorized
purchase in the City of Cottage Grove.

My credit, debit, or other type of financial card was used to make unauthorized purchases
somewhere other than the City of Cottage Grove. Where?

My account number (not a financial card) was used to make an unauthorized transaction(s)
and/or purchases in any city/state, or via the internet.

My personal information (name, social security number, date of birth, driver’s license number, etc.) was
used to create a new unauthorized financial account?

My credit, debit, or other type of financial card was used to make unauthorized
transactions, but my actual card is still in my possession.
Please gather the information listed below, complete this packet, and file a report with the
Cottage Grove Police Department.
The following documentation will be required prior to opening an investigation:
• Affidavit of Fraud/Forgery (signed and notarized).
• A copy of account statements that indicate the date, time, and location of any unauthorized use.
• Completed attached forms.
• Please contact the fraud department of your bank or Credit Card Company and ask that they indicate
in their file the Cottage Grove Police Department case file number and that you will authorize the
release of account information specific to the fraud.
PLEASE COMPLETE AND RETURN THIS PACKET AS SOON AS POSSIBLE
Upon the initial report to the Cottage Grove Police Department, this incident will be listed as an “Identity
Theft Report”. Once the attached documentation is completed and returned, the police department will
review the case and, if applicable, assign the case for criminal investigation. If all necessary
documentation is not received within 30 days of the report to police, the case file will be inactivated.
CASE FILE:___________________
COTTAGE GROVE POLICE DEPARTMENT FRAUD INFORMATION
*Primary Officer: Badge# *Date:
*Victim’s Contact Info
Name (Last, First, Middle):

DOB:
Home Address:
City: Zip:
Cell Phone: Home Phone: Work Phone:
*ACCOUNT DATA (If multiple accounts involved, use a separate sheet for each)
*Type of Card: Visa [ ] MasterCard [ ] Discover [ ] Other:
*Bank Name: *Account number:
*16 digit number on card: *Joint account holder:
*FRAUD DATA (note additional information on a separate sheet)
Transaction
Amount
Location of Transaction
(Include store name, address, city, or store number)
Date of
Transaction
Time of
Transaction
(Include Time Zone)











*CONTACT DATA (list names and contact numbers of any fraud department persons you have spoken with)
Bank (or credit card company):
Contact Name: Contact number:
Other information:
*=Required Field. If not applicable to your case, write “N/A”
Please do not write in this section
Officer’s notes:
(Indicate location/jurisdiction, significant points of compromise to the card/account, or any other important details)
CASE FILE:___________________
On the following page you will find an Affidavit of Fraud or Forgery.
This is a legal document that must be signed, notarized, and is required for
prosecution.
An Affidavit of Fraud or Forgery is also required by many financial
institutions for disputed charge/fraud reports.
Although some of the information requested on the Affidavit of Fraud or
Forgery is repetitive to what you may have already completed on previous
pages, it is important that this form is complete.
A notary is available at the Cottage Grove Police Department lobby,
Monday through Friday 8:00 a.m. to 4:30 p.m.
(excluding holidays).
CASE FILE:___________________
Affidavit of Fraud or Forgery
STATE OF MINNESOTA
COUNTY OF WASHINGTON
I, , being duly sworn on oath, state as follows:
(PrintName)
(1) that I am at least 18 years old;
(2) that I have examined the statement, deposit, draft, withdrawal, or other transaction described
below; and
(3) that payment of the item was not authorized by me because:
Forged or unauthorized account holder signature.
Unauthorized withdrawal.
Unauthorized use of stolen/lost financial card.
Unauthorized use of financial account information.
Briefly list the transaction amount(s), transaction location(s), and transaction date(s)/ time(s) below:
I also state as follows:
(1) that I have not signed or altered the item(s) referred to above, and that I have not authorized my
signature on the item(s) or alteration of the item(s);
(2) that I have received no payment or benefit (directly or indirectly) as a result of the payment of the
item(s) referred to above;
(3) that I will provide any information I have as to the person who is responsible for signing my name
on the item or altering the item; and
(4) that all my statements above are true and that I will cooperate fully in the investigation and
prosecution of this matter.
Signature: Address ______________________________________
Telephone
Subscribed and sworn to before me this _____ day of ________________________, 20_____.
Notary:
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COTTAGE GROVE POLICE DEPARTMENT FINANCIAL CRIME PACKET (City of Cottage Grove)

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Completed 12 February 2021

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