Access Device Fraud Incident Report Form
Use this form to report suspected or confirmed fraud involving an access device and provide the details needed for review and follow-up.
Reporter Information
Full Name
*
First Name
Middle Name
Last Name
Job Title / Role
Organization / Department
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Incident Overview
Incident Date
*
-
Month
-
Day
Year
Date
Date and Time Fraud Was Discovered
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location or Channel
*
Please Select
In person
Online
Mobile app
Phone
ATM
Point of sale terminal
Email
Other
Incident Status
*
Suspected
Confirmed
Ongoing
Fraud Category or Type
*
Please Select
Card-not-present misuse
Lost or stolen device misuse
Device cloning or skimming
Unauthorized account access
Cash withdrawal fraud
Payment transfer fraud
Other
Short Incident Summary
*
Detailed Description of What Happened
*
Access Device and Account Details
Access device type
*
Please Select
Physical card
Mobile wallet
Key fob
Building badge
Security token
Other
Masked device identifier or reference number
*
Last 4 digits of the card, if applicable
Issuing department or provider
Account or asset nickname / reference
*
Is the device currently in your possession?
*
Yes
No
Not sure
Current status of the device
*
Lost
Stolen
Cloned
Compromised in another way
Unauthorized Activity Details
Did unauthorized transactions occur?
*
Yes
No
Unsure
Transaction date and time range
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Merchant or service name
Transaction amount range
Please Select
Under $50
$50-$199
$200-$499
$500-$999
$1,000 or more
Exact amount available
Unknown
Number of suspicious transactions
How was the activity detected?
*
Account alert
Paper statement review
Mobile app notification
Email notification
Merchant contact
Card not present alert
Reviewed by bank or processor
Other
Immediate Actions Taken
Actions already taken
*
Device disabled
Card/account frozen
Access changed
IT/security notified
Law enforcement contacted
Merchant contacted
Monitoring initiated
Other
If access was changed, describe the change
IT/security team notified by
Date and time IT/security was notified
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Law enforcement agency contacted
Date and time law enforcement was contacted
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Merchant contacted
Additional action details
Evidence and Documentation
Supporting Documentation
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Case Reference Number
Additional Notes on Evidence
Follow-Up and Authorization
Preferred Follow-Up Method
*
Email
Phone
Text message
Other
Best Time to Contact
Hour Minutes
AM
PM
AM/PM Option
Request Updates
Yes, please keep me updated
Only if additional information is needed
No updates requested
Special Instructions or Additional Information
Submit Report
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