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Check Handling Information APPENDIX I and Procedure 7/14 Page 12

Stolen Check Report All questions must be answered

Date of Report_______________________Payee__________________________________________________________ Address of Payee______________________________________________________________________________ ____________________________________________________________________________________________ Phone #: Home ______________________ Work _________________________ Cell ______________________

Check Number _____________ Amount _______________ Date of Check_____________

Were any other items, such as identification, taken? Yes No If so, what type ___________________________________ ID Number _________________________________

Where did the theft occur? Home Work Auto Other ______________________________________

Do you have any idea who may have taken this check? Yes No If so, who?_________________________

Description of Suspect: Height ________ Weight ________ Sex _________ Age ________ Race ____ Address of Suspect____________________________________________________________________________ ____________________________________________________________________________________________ Why do you suspect this person? _________________________________________________________________ ____________________________________________________________________________________________ How do you know this person? __________________________________________________________________ ____________________________________________________________________________________________ Is this person related to you? Yes No If so, what relation is this person to you? ________________ Have you moved in the last 60 days? Yes No Please attach a separate piece of paper that lists all other adult household members in the home at the time of the theft. A police report must be filed when a Stolen Check Report is made. Police report number: __________________ I agree by signing this report to cooperate with the Department of Social Services and any law enforcement agencies in the investigation and/or prosecution of any person(s) who may be responsible. (This information will be supplied to the financial institution who negotiated the check and law enforcement agencies to assist in prosecution.) Additionally, I state that this information is true and correct, and understand that making a false sworn statement is subject to federal and/or state statutes and may be punishable by fines and/or imprisonment. Please sign your name on the following lines:

__________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ ___________________________________ ___________________________________