Real Estate Fraud Complaint Form Page 2
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6Drivers‟ license no. of person(s)
Birthdate(s)
Social Security no(s):
AKAs (if known):
:
25
26
27
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you are filing against
:
(if known)
a)
___________________
a)
_______________
a)
________________________
a)
________________________
b)
___________________
b)
_______________
b)
________________________
b)
________________________
c)
___________________
c)
_______________
c)
________________________
c)
________________________
(
Personal descriptions of those involved
list name, race, sex, age [or approximate age if birthdate is not listed in box # 26], height, weight, color of eyes
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& hair, tattoos, scars and any other descriptive information
)
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Do you suspect a forgery has been committed?
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Yes ___
No ___
Identity Theft? Yes ___
No ___
Are you complaining about a mechanics lien?
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Yes ___
No ___
How and when did you first become aware of the alleged fraud?
Date and place where the transaction(s) occurred:
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Have you had a previous business or personal relationship with the person/firm or any of its partners, officers, directors or
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controlling person?
Yes __
No __
Business
__
Personal
__
Former employee
__
How Long? ____
If yes to # 34, please write the exact name or entity, and very briefly explain the relationship. Provide dates if you can.
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Yes__
No__
Have you contacted the business or person regarding your complaint?
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If Yes, person(s) contacted and date(s) contacted:
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_______________________________________
Date(s)______________________________
_______________________________________
Date(s)______________________________
_______________________________________
Date(s)______________________________
_______________________________________
Date(s)______________________________
_______________________________________
Date(s)______________________________
YOU MUST SIGN AND DATE PAGE 6 OF YOUR COMPLETED FORM
WHETHER OR NOT YOU HAVE ADDITIONAL STATEMENT PAGES ATTACHED
Page 2 of 6
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