HSMV Form 72068 (Rev 07/11) Page 1 of 2
STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY
AND MOTOR VEHICLES
DIVISION OF MOTORIST SERVICES
Fraud Investigation Requests
This form is to be completed ONLY when a victim is affected by driver license or identification card fraud. If
your complaint is in regard to a citation, you must contact the court where the citation was issued to resolve
the matter.
Date of Complaint: Time of Complaint: AM PM
Office Number: Address:
DHSMV Representative’s Name and ID Number:
Complaint originated from: Victim Law Enforcement Other
If the complaint originated from Law Enforcement or Other, please list the contact information to include agency,
officer’s name, address and telephone number.
Has any formal complaint been made with any Law Enforcement or other government entity in connection with this
complaint? Yes No
If yes, please list the agency name, officer’s name, case number and contact information.
Has the victim had any identification documents stolen or lost? Yes No
List the items and approximate date of loss:
Would the victim like to have his/her record flagged? Yes No
Victim/Complainant Information
Name:
First Middle Last (Maiden or Mother’s Maiden Name)
Address:
Current or Last Known Mailing Address
Florida DL/ID Number: OOS DL/ID Number:
Telephone: Work: Home: Cell:
Email Address: Social Security Number:
Types of DL/ID Fraud
Florida DL/ID Fraud Counterfeit
Address Fraud Out of State **
Certificate Fraud
(marriage, birth, social security or passport)
Does the victim know the imposter? Yes No
Is the imposter related to the victim? Yes No If yes, what is the relationship?
City/County/State where the imposter may be located:
BMC Fraud Section Use Only
Fraud Case Number
Date Received
** Must provide copy of photo ID, birth certificate, social security card
and sample signature.
PLEASE COMPLETE THE SECOND PAGE OF THIS FORM
