PAC CLAIMS – Check Fraud Investigation Request Form

Check Fraud Claim (PACIFIC CLAIMS)

Required by Chase to process suspected check fraud items

Step 1 of 2 - Declaration of Unauthorized Endorsement or Altered Item

50%

Today's Date

MM slash DD slash YYYY

Check Payable To:

Check #

Check Date

MM slash DD slash YYYY

Check Amount

Mark the box next to the reason for your claim

Forged endorsement: Someone else endorsed the check with my name.

Improper endorseement: The endorsement does not match the payee on the check.

Missing endorsement: The check was not endorsed (payee non-receipt of funds).

Altered check: I (Maker) did not alter the check or grant permission to alter this check, but the payee was changed.

Altered Name (name the payee was changed to without authorization)

Original Name (Name of the Original Payee Esparza wrote the check to)

Original Amount

Altered Amount

1. On what date did you become aware of the unauthorized document or alteration to the check?(Required)

MM slash DD slash YYYY

2. Was the check lost or stolen?

Yes

If yes, when and where did this happen?

3. Was the check mailed?

Yes

a. If yes, when and where was the check stolen?

Did you file a claim with the U.S. Postal Service?

Yes

What was the Postal Claim Number?

4. If you suspect a specific person, please file a police report. Provide the person's name and your relationship with the person below. Please include a copy of the police report with the declaration.

5. CHECK MAKER / Statement of Fact: Please provide any additional information regarding your claim.

PAYEE / Statement of Fact: Please provide any additional information regarding your claim.

Click for an Info Request Form

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