Fraud Collection Claimant Information
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1FRAUD COLLECTION
Claimant Information
Provide any information that is available and/or pertinent to the claim.
Name __________________________________________ Social Security No
Spouse's Name __________________________________ Social Security No.
Address
Daytime Telephone ____________________
Evening Telephone
What happened?
When did it happen?
Where did it happen?
Was check/warrant signed?
Was check/warrant stolen from mailbox?
Do you think any other mail was stolen?
Do you suspect anyone in particular?
If so, describe the person and give his or her name and address, if known:
Why do you suspect this person?
Did you file a report with law enforcement?
Date:
Contact Name
Telephone Number
c:\users\honeyma\desktop\web temp\c-17 fraud collection-claimant info.doc
SL 3 Revised 12/17/2009
C-17
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