IMPORTANT NOTICE
This form is not subject to the requirements of Pub. L. 96-511 ''Paperwork Reduction Act of 1980." 44 U.S.C., Chapter 35, Section 3518 (c)(1)(A) states that, "...this chapter [Chapter
35] does not apply to the collection of information ... during the conduct of a Federal criminal investigation..."
PLEASE SUBMIT TO THE LOCAL SECRET SERVICE JURISDICTIONAL FIELD OFFICE
POINT-OF-CONTACT:
INSTRUCTIONS TO BANK:
1. Prepare and submit one copy of this completed form with each suspected counterfeit note to your local SECRET SERVICE OFFICE.
2. If desired, an additional copy of this form should be prepared and retained for your records.
3. Unless advised otherwise, the suspect note submitted to the Secret Service should be considered counterfeit.
4. The Secret Service WILL NOT return a copy of this form.
MAILING ADDRESS OF BANK: (include ZIP Code)
DO NOT WRITE IN THIS SPACE
Classification Number
POINT-OF-CONTACT'S TELEPHONE NUMBER: (include area code)
DESCRIPTION OF COUNTERFEIT NOTE OR RAISED NOTE (for raised note give serial number only)
FEDERAL RESERVE BANK (Series 1996 - Letter/Number) NOTE POSITION LETTER/NOTE POSITION NUMBERDENOMINATION
SERIAL NUMBER SERIES BACK PLATE NO.
NOTE POSITION LETTER/FACE
PLATE NO.
COUNTERFEIT NOTE RECEIVED FROM
NAME OF INDIVIDUAL / BUSINESS
HOME PHONE (with Area Code)
HOME ADDRESS (OR BUSINESS LOCATION WHERE COUNTERFEIT WAS PASSED)
BUSINESS PHONE (with Area Code)
NAME OF TELLER RECEIVING AND INITIALING NOTE
NAME OF PERSON SURRENDERING AND INITIALING NOTE
INFORMATION ABOUT COUNTERFEIT NOTE
NoYesDOES THE CUSTOMER HAVE ANY INFORMATION AS TO THE SOURCE OF THE COUNTERFEIT?
REMARKS:
DISPOSITION (For Secret Service Use Only)
Genuine note and SSF 1604 returned to bank (Receipt No. )
Page 1 of 1
SSF 1604 (Rev. 09/2015)
WAS THERE ANY SUSPICIOUS ACTIVITY?
IS THIS A NON - CUSTOMER?
Yes
Yes
No
No
DATE OF ACTIVITY OR DEPOSIT
DEPARTMENT OF HOMELAND SECURITY
United States Secret Service
COUNTERFEIT NOTE REPORT
NAME OF BANK:
POINT-OF-CONTACT'S E-MAIL: (if different from above)
POINT-OF-CONTACT'S FAX NUMBER: (include area code)
BANK ROUTING NUMBER:
Bank tellers and persons surrendering the note should date and initial each counterfeit note one time with pen and ink in the border area of the note for identification. If the person
surrendering the note knows from whom he/she received it, or has a description of the passer, or his/her auto, or any other information, TELEPHONE the local police department
or Secret Service office IMMEDIATELY and hold the note. (The telephone number of the nearest Secret Service office may be found at www.secretservice.gov
.) Otherwise, if no
information is available, please mail the note to the Secret Service local office on the day it is received. The submitting bank agrees to abandon any property interest in counterfeit
notes it surrenders to the Secret Service.
