Fill and Sign the Residential Tenancy Agreement Victoria PDF Form

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: DO NOT WRITE IN THIS SPACE 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) 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. DESCRIPTION OF COUNTERFEIT NOTE OR RAISED NOTE (for raised note give serial number only) DENOMINATION FEDERAL RESERVE BANK (Series 1996 - Letter/Number) CHECK LETTER/FACE PLATE NO. BACK PLATE NO. SERIES CHECK LETTER/QUADRANT NO. 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..." SSF 1604 (Rev. 08/2013) PLEASE SUBMIT TO THE LOCAL SECRET SERVICE JURISDICTIONAL FIELD OFFICE Page 1 of 1