Counterfeit Reporting Form (To be…

                                Counterfeit Reporting Form

 (To be used by banks being presented with counterfeit cashier's checks, official
            checks, or money orders drawn on their own institution.)

                  Information                                          Bank Response
Bank Name
Bank Address
City
State, Zip
Type of Instrument
(Cashier's Checks / Official Checks)
Description of Instrument
(Counterfeit/Fictitious/Stolen)
Bank Routing Number
Do the items display the correct routing
number? (Yes/No)
Do the counterfeit instruments resemble the
authentic items? (Yes / No)
Description of Counterfeit Items
(Include colors, banners, watermarks,
encoding, etc.)

PLEASE PROVIDE COPY IF AVAILABLE.

Volume of Counterfeit Items (Approximate)
Are the items being presented locally, nation-
wide or both?
Nature of Transaction (Lottery Scam, Internet
Purchase, etc.) Please provide any additional
documentation you may have received.
Description of Authentic Items
(Include colors, banners, watermarks,
encoding, etc.)

PLEASE PROVIDE COPY.

Bank Contact Information (How do you want to be contacted?) This information will be posted
on the Alert document.
Name, Position, Department
Phone Number
Fax Number
Email Address
Website
Copies of Counterfeit Items Attached (Yes/No)
Copies of Authentic Items Attached (Yes/No)
Name, Title & Telephone Number of Person
Completing Form

Please note that for security reasons copies of the items will not be posted to the Internet. This form and
any attachments may be returned to us via mail at: Special Supervision Division, Comptroller of the
Currency, 250 E Street, SW, Mail Stop 6-4, Washington, DC 20219, via fax at (202) 874-5214 or via
email at: occ alert responses@occ.treas.gov

 ** THIS FORM IS NOT TO BE USED FOR REPORTING COUNTERFEIT CURRENCY. PLEASE SEE
             THE US SECRET SERVICE WEBSITE FOR ADDITIONAL GUIDANCE. **