Bank Account Fraud Form

Please complete this Bank Account Fraud Form if your agency has experienced actual bank account fraud that has resulted in a financial loss.

If you have not notified your banking institution, please do so before completing this form. When completing this form, include as much detail as possible so that appropriate follow-up actions can be taken to recover the funds or prevent future fraud occurrences.

If you have questions, please reach out to [email protected].

(Please complete one form for each occurrence of actual fraud after reporting it to your bank.)

State Agency Name (required)

Enter the full agency name - DO NOT use acronyms.

State Agency Contact (required)

Position (required)

Phone (required)

Email (required)

Please note: this email will receive the submission confirmation for this form.

Date Reported to Bank (required)

Bank Name (required)

Account Name (required)

Last Four Digits of Account Number (required)

Type of Fraud

Check Fraud

ACH / Wire Fraud

Business Email Compromise or Account Takeover

Other, please explain in the box below

Nature of Fraud (required)

Please describe the nature of fraud that occurred in the box below providing as much detail as possible:

Transaction Date of Fraud (required)

Amount (required)

Payee Name (required)

Bank of First Deposit (BOFD) if applicable

Please attach any documents you have shared with the bank about this fraud instance

Choose file

One file only.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Bank Account Fraud Form

Please complete this Bank Account Fraud Form if your agency has experienced actual bank account fraud that has resulted in a financial loss.

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