Red Flag Incident Report

Red Flag Incident Report

(for Corporate Compliance Officer’s Review and Completion)

Date: ___ / ___ / ____ Department: ______Contact Name: ______

Contact Phone: ______Red Flag Type: ______

Account Information (please supply all applicable information)

Name:

Address:

Date:

Amount:

Account/Transaction/Invoice Number:

Documentation included: ______

Describe Red Flag detection and actions: ______

For Corporate Compliance Officer’s Use Only

Describe mitigation process or actions: ______

Incident Report Number: (format mm/dd/yy/nn where nn = incident number) ___/___/___/___

Received by: ______

Instructions for Red Flag Incident Report

Date – the date the report is being filed

Department – name of the department or area

Contact Name – name of supervisor/manager completing the report

Contact Phone – internal phone number of the contact supervisor/manager

Red Flag Type– Select from one of the following:

1)Notifications and Warnings from Consumer Credit Bureaus

2)Suspicious Documents

3)Suspicious Personal Identifying Information

4)Suspicious Covered Account Activity

5)Alerts from Others

Specific Account Information

Name – name of the account owner or consumer

Address – address of the account owner or consumer

Date – date the Red Flag for this account/transaction was first detected

Amount – any dollar amount associated with the transaction involved with the Red Flag Account/Transaction/InvoiceNumber – any identifying information associated with the transaction, account, or invoice

Documentation included – List copies of any documentation associated with the transaction or account with regards to the detection of the Red Flag, including, but not limited to:

1)electronic signatures

2)voice conversation notes

3)correspondence

Describe Red Flag detection and actions – Describe how the Red Flag was detected and the corresponding actions performed by the employee, supervisor or manager involved in the investigation and escalation.

For Corporate Compliance Officer Only

Describe mitigation process or actions – Describe actions taken by the Corporate Compliance Officer, including, but not limited to:

1)Correspondence to and from the original owner of an account

2)Any final determination of fraud

3)Any correspondence to any law enforcement agency, state regulatory agency, etc.

4)Any actions performed by the Corporate Compliance Officer to alleviate and mitigate any identified actual fraud

Incident Report Number– mm/dd/yy/nn – month, day, and year the report was received by the Corporate Compliance Officer, with nn being a sequentially assigned number for the individual identification of this incident.

Received by– signature of the Corporate Compliance Officer or his/her designee