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2. Alliance Police Department Forgery Packet

   **Use this packet when the case involves a forgery. This could include many documents and transactions as well.**

   
   

3. 
5. AUTHORIZATION FOR DISCLOSURE OF FINANCIAL ACCOUNT INFORMATION
7. I Authorize

   (name/address of account holder) to release the financial information of the individual names below: 

9. Account Holder Name:
11. Bank Name:
13. Bank Address
15. Bank Contact Person:

17. I authorize the information to be disclosed and discussed with the Alliance Police Department, the Box Butte County Attorney's Office, or the Nebraska Attorney General's Office. 

    The type and amount of information to be disclosed is as follows: 

19. Entire bank record from:
    Entire bank record from: Start Date

    —

    Entire bank record from: End Date
20. Entire credit card statement from:
    Entire credit card statement from: Start Date

    —

    Entire credit card statement from: End Date

22. Copy of signature card or similar type document showing the account holder(s) signature.

    I understand this authorization will expire, without my express revocation, one year from the date of signing, or if I am a minor, one year from the date of signing or on the date I become an adult according to state law, whichever is earlier. I understand I may revoke the authorization at any time except to the extent that action has been based on this authorization. I understand the revocation must be in writing and presented to the provider named above. I understand my authorization is not needed under some conditions as previously explained pursuant to a notice received from the provider named above and any revocation in writing of this authorization does not affect the ability of the provider named above to disclose information otherwise allowed by law. I understand I have a right to a copy of this authorization.

    I understand that authorization for the disclosure of this financial information is voluntary and I can refuse to sign this authorization. I understand any disclosure of information carries with it the potential for re-disclosure and the information may not be protected by federal law or regulations.

24. Signature of Account Holder or Authorized Personal Representative
25. Date
    Date
27. Signature of Account Holder or Authorized Personal Representative
28. Date
    Date
32. FRAUD REPORTING FORM

    *Complete one form for EACH credit/debit card fraudulently used. 

34. Type of transaction device fraudulently used:
    -- Select One --Credit/Debit CardFinancial/Checking Account
36. Was the Debit/Credit card:
    -- Select One --StolenLostStill in your possession
38. Was a police report filed at the time of the theft or loss of the credit/debit card?
    -- Select One --YesNo
39. If yes, Agency Name:
40. If Yes, Case Report Number:
42. Card Information:
44. Type of Card:

    1. Debit Card
    2. Credit Card
    3. MasterCard
    4. VISA
    5. American Express
    6. Discover
    7. Other
45. If Other:
47. Debit Card:
48. Debit Card Account Number:
49. Expiration Date:
51. Associated Check Account Number:
52. Bank:
53. Branch Location:
55. Name as it appears on the card:
57. Credit Card:
58. Credit Card Account Number:
59. Expiration Date:
61. Name as it appears on the card:
63. Type of Fraud:

    1. Unauthorized Use
    2. Forgery
    3. Embezzlement
    4. Identity Theft
    5. Unauthorized Account/Card
    6. Internet Fraud
    7. Other
64. If Other:
66. Date of Transaction
    Date of Transaction
67. Amount:
68. Location Used:
69. City/State:
71. Date of Transaction
    Date of Transaction
72. Amount:
73. Location Used:
74. City/State:
76. Date of Transaction
    Date of Transaction
77. Amount:
78. Location Used:
79. City/State:
81. Date of Transaction:
    Date of Transaction:
82. Amount:
83. Location Used:
84. City/State:
86. Did you report this to your bank?
    -- Select One --YesNo
87. If Yes, Contact Name:
88. If Yes, Contact Phone:
92. Forgery Report Instructions

    *Alliance Police Department Staff Use Only

94. 1. Have the involved victim/witness complete an attached Forgery Witness Form.
96. 2. Place a checkmark next to any of the following evidence that may apply to this incident (attach any items that are checked):

    1. Photograph of account holder at time account was opened
    2. Surveillance video or photographs of suspect involved in incident
    3. Affidavit of forgery
    4. Original or copy of forged check
    5. Ink print of right index finger obtained at time account was opened, and at the time of transaction
    6. Contact name and information
    7. Originals or copies of identification used by check presenter
100. Incident Summary Form
102. Incident Details:
104. Date and Time of Incident
     Date and Time of Incident

     Date and Time of Incident
106. Name of Business:
107. Physical Address of Business:
109. Employee Check was Presented to:
110. Employee Title:
112. Forged Check Details:
114. Payee Name:
115. Payee Address:
116. Payee Phone:
118. Payee Identification Number:

     (indicate State)

119. Payee Account Number:
121. Check Number:
122. Check Amount:
124. Account Number Check is drawn off:
125. Check Maker Name:
127. The check was determined to be a forged instrument based on the following reason(s):

     (e.g. reported stolen, contact with the account holders, quality of document, etc....) 

     **BE AS DETAILED AS POSSIBLE

129. Location & Witness Information:
131. Business Name:
132. Physical Address of Business where check was presented:
133. Business Phone Number:
135. Witness Name:
136. Witness Title:
137. Witness Date of Birth:
139. Date/Time Check Presented:
     Date/Time Check Presented:

     Date/Time Check Presented:
141. Suspect Check Information:
143. Suspect Name:
144. Suspect Address:

     (if known)

145. Suspect Phone:

     (if known)

147. Payee Identification Number:

     (indicate State)

148. Suspect Account Number:

     (if applicable) 

150. Check Number:
151. Check Amount:
153. Account Number Check is drawn off
154. Bank Check is drawn off
155. Check Maker Name:
157. Description of Suspect & Vehicle:

     Complete any that are applicable 

159. Sex:

     1. Male
     2. Female
160. Race:
161. Approx. Age:
162. Approx. Height:
164. Approx. Weight:
165. Hair Color:
166. Eye Color:
168. Clothing:
170. Scars, Marks, or Tattoos:
172. Any other distinguishable features:
174. Vehicle Information:

     (Make, Model, Color, License Plate, etc.)

176. Additional Information:
178. Can you identify the suspect?
     -- Select One --YesNo
179. Will you aid in the prosecution?
     -- Select One --YesNo
180. Did the suspect present the forged check to you?
     -- Select One --YesNo
182. What identification did the suspect present? (check type)?

     1. Drivers License
     2. ID
     3. Passport
     4. Military ID
     5. Other
183. If Other:
184. ID Number:
186. Did you record the ID Number and type on the forged check?
     -- Select One --YesNo
187. If a photo ID was used, was the picture compared to the suspect?
     -- Select One --N/AYesNo
188. If Yes, did the picture appear to be of the suspect?
     -- Select One --YesNo
189. Did the suspect endorse/sign the forged check in your presence?
     -- Select One --YesNo
191. The check was determined to be a forged instrument based on the following information:

     (e.g. reported as stolen, contact with account holder, quality of document, etc.) *BE DETAILED WITH YOUR EXPLANATION.

193. Include a brief synopsis of the events related to the forged instrument that was presented:
195. Do you have any additional information which will assist in locating the suspect?
Leave This Blank:


197. 1. Receive an email copy of this form.
198. Email address

     This field is not part of the form submission.

199. Submit

* indicates a required field