Fraud Incident Report Form

Fraud reported by (name)*:

Fraud reported on (date):
Contact details of person reporting fraud: Email address:
Phone number:
Mobile phone number:
Postal address:
Date of potential / reported fraud:
Description of potential fraud (please provide as much detail as you can):

Location of potential fraud:

Approximate value of potential fraud ($):
Name(s) of person (s) that may have committed the potential fraud:
Name of the organisation/company for whom the person that may have
committed the potential fraud works:
Do you have any supporting documentation (including photos and/or
video) that may assist us in an investigation?
Have you reported the potential fraud to anyone else? Yes / No
If you have reported the fraud previously, to whom did you report it?
If you have reported the fraud previously, when did you report it?
Name of the person that received the Fraud Incident Report
Signature of person that received the Fraud Incident Report
Date Fraud Incident Report received

* While a person reporting a fraud may remain anonymous, an anonymous report makes investigating and prosecuting the matter significantly
more difficult than if the person making the report provides their identity.