[Iowa DOT] 493001- Fraud Incident Report

Fraud Incident Report

Date of Incident

Date Picker

Time of Incident

Incident Type

CDL Testing

DL/ID

Team Member

Location of Incident (include county #)

CustFN

CustMN

CustLN

Address

Driver License Number

Date of Birth

SSN

ID Type Applied For

False Name Used?

Yes

No

False First Name Used

False Middle Name Used

False Last Name Used

False License Number

False Social Security #

False Date of Birth

False Address Used?

Yes

No

SPEX/State(s)

Notice Given

Yes

No

Investigator Notified

Yes

No

Central Programs Bureau Notified

Yes

No

Documents Presented

Birth Certificate

Not provided

Valid

Altered

Counterfeit

Upload File(s): Birth Certificate

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Social Security Card

Not provided

Valid

Altered

Counterfeit

Upload File(s): Social Security Card

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Resident Alien Card

Not provided

Valid

Altered

Conterfeit

Upload File(s): Resident Alien Card

Click Here to Upload

Employment Authorization

Not provided

Valid

Altered

Counterfeit

Upload File(s): Employment Authorization

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I-94

Not provided

Valid

Altered

Counterfeit

Upload File(s): I-94

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Passport

Not provided

Valid

Altered

Counterfeit

Upload File(s): Passport

Click Here to Upload

Out-of-State ID/DL

Not provided

Valid

Altered

Counterfeit

Upload File(s): Out-of-State ID/DL

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Were other documents presented?

Yes

No

Other Documents

Upload File(s): Other Documents

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Narrative/Comments (Please include date and time.)

Document Signers

- Reporter