Note Report Form PDF Details

The Counterfeit Note Report form, issued by the United States Secret Service, a part of the Department of Homeland Security, serves as a vital document for banking institutions in the pursuit of upholding the integrity of the United States currency system. Through meticulous instructions, the form guides banks on how to properly submit a suspected counterfeit note for examination, emphasizing the importance of cooperation between financial institutions and law enforcement. By stipulating the submission of one copy of the completed form along with the counterfeit note to the nearest Secret Service office, the protocol ensures a systematic approach to counterfeit detection. The form also allows banks to keep a copy for their records, underscoring the significance of meticulous record-keeping in financial operations. Highlighting critical information such as the bank's name, routing number, and the point-of-contact details, alongside a comprehensive description of the counterfeit note, ensures that each report is detailed and precise. The mandate that the suspect note be initially dated and initialed by the person surrendering it provides an additional layer of security and traceability. Moreover, the form stresses immediate communication with local authorities if any information about the source of the counterfeit note is available, showcasing the proactive measures taken to combat this form of financial crime. In essence, the Counterfeit Note Report form exemplifies the concerted effort between the banking sector and law enforcement agencies to protect the nation’s currency system from fraudulent activities.

QuestionAnswer
Form NameNote Report Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesus secret service counterfeit bill, counterfeit note report, us secret service counterfeit form, secret service counterfeit bill form

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DEPARTMENT OF HOMELAND SECURITY

United States Secret Service

COUNTERFEIT NOTE REPORT

INSTRUCTIONS TO BANK:

1.Prepare and submit one copy of this completed form with each suspected counterfeit note to your local SECRET SERVICE OFFICE.

2.If desired, an additional copy of this form should be prepared and retained for your records.

3.Unless advised otherwise, the suspect note submitted to the Secret Service should be considered counterfeit.

4.The Secret Service WILL NOT return a copy of this form.

NAME OF BANK:

BANK ROUTING NUMBER:

POINT-OF-CONTACT:

POINT-OF-CONTACT'S E-MAIL: (if different from above)

POINT-OF-CONTACT'S TELEPHONE NUMBER: (include area code)

POINT-OF-CONTACT'S FAX NUMBER: (include area code)

MAILING ADDRESS OF BANK: (include ZIP Code)

DO NOT WRITE IN THIS SPACE

Classification Number

IMPORTANT NOTICE

Bank tellers and persons surrendering the note should date and initial each counterfeit note one time with pen and ink in the border area of the note for identification. If the person surrendering the note knows from whom he/she received it, or has a description of the passer, or his/her auto, or any other information, TELEPHONE the local police department or Secret Service office IMMEDIATELY and hold the note. (The telephone number of the nearest Secret Service office may be found at www.secretservice.gov.) Otherwise, if no information is available, please mail the note to the Secret Service local office on the day it is received. The submitting bank agrees to abandon any property interest in counterfeit notes it surrenders to the Secret Service.

DESCRIPTION OF COUNTERFEIT NOTE OR RAISED NOTE (for raised note give serial number only)

DENOMINATION

FEDERAL RESERVE BANK (Series 1996 - Letter/Number)

NOTE POSITION LETTER/NOTE POSITION NUMBER

NOTE POSITION LETTER/FACE PLATE NO.

BACK PLATE NO.

SERIES

SERIAL NUMBER

COUNTERFEIT NOTE RECEIVED FROM

NAME OF INDIVIDUAL / BUSINESS

DATE OF ACTIVITY OR DEPOSIT

HOME ADDRESS (OR BUSINESS LOCATION WHERE COUNTERFEIT WAS PASSED)

HOME PHONE (with Area Code)

BUSINESS PHONE (with Area Code)

NAME OF PERSON SURRENDERING AND INITIALING NOTE

NAME OF TELLER RECEIVING AND INITIALING NOTE

INFORMATION ABOUT COUNTERFEIT NOTE

DOES THE CUSTOMER HAVE ANY INFORMATION AS TO THE SOURCE OF THE COUNTERFEIT?

 

Yes

 

No

WAS THERE ANY SUSPICIOUS ACTIVITY?

 

Yes

 

No

 

 

IS THIS A NON - CUSTOMER?

 

Yes

 

No

 

 

 

 

 

 

 

REMARKS:

 

 

 

 

 

 

 

 

 

DISPOSITION (For Secret Service Use Only)

Genuine note and SSF 1604 returned to bank (Receipt No.

 

)

This form is not subject to the requirements of Pub. L. 96-511 ''Paperwork Reduction Act of 1980." 44 U.S.C., Chapter 35, Section 3518 (c)(1)(A) states that, "...this chapter [Chapter 35] does not apply to the collection of information ... during the conduct of a Federal criminal investigation..."

PLEASE SUBMIT TO THE LOCAL SECRET SERVICE JURISDICTIONAL FIELD OFFICE

SSF 1604 (Rev. 09/2015)

Page 1 of 1

 

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1. For starters, when filling in the counterfeit note report pdf, begin with the area that features the following blank fields:

Completing section 1 in counterfeit report

2. The subsequent part would be to submit all of the following blanks: COUNTERFEIT NOTE RECEIVED FROM, NAME OF INDIVIDUAL BUSINESS, DATE OF ACTIVITY OR DEPOSIT, HOME ADDRESS OR BUSINESS LOCATION, HOME PHONE with Area Code, BUSINESS PHONE with Area Code, NAME OF PERSON SURRENDERING AND, NAME OF TELLER RECEIVING AND, INFORMATION ABOUT COUNTERFEIT NOTE, DOES THE CUSTOMER HAVE ANY, WAS THERE ANY SUSPICIOUS ACTIVITY, IS THIS A NON CUSTOMER, REMARKS, Yes, and Yes.

Guidelines on how to prepare counterfeit report step 2

Many people generally get some points wrong when completing DOES THE CUSTOMER HAVE ANY in this section. Ensure that you go over whatever you enter here.

3. The following section is about Genuine note and SSF returned to, This form is not subject to the, SSF Rev, PLEASE SUBMIT TO THE LOCAL SECRET, and Page of - type in each one of these fields.

counterfeit report conclusion process outlined (part 3)

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