FORGERY/CREDIT CARD ABUSE
SELF-REPORTING FORM

This form is to be completed by the victim business only. The person who accepted the
check or credit card should be the one to fill out the form.

You may complete the application online and then download it and mail it
to the address shown on the form.

The Adobe® Acrobat® Reader™ is required to view and complete the application. If you do not
have this program installed on your computer, you can download it for free
by clicking on the logo below.

Self-Reporting Form