"Fraud Report Form" - Minnesota

Fraud Report Form is a legal document that was released by the Office of the Minnesota Attorney General - a government authority operating within Minnesota.

Form Details:

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  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Office of the Minnesota Attorney General.

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Fraud Report Form
The Office of the
Minnesota Attorney General
helping people afford their lives and live with dignity and respect
Information About You
Information About the Scammer
(if known)
Your Name
Suffix (Jr., Sr., etc.)
Name of Person or Entity
Street Address
Street Address
City, State, Zip
City, State, Zip
Primary Phone
Phone Number
Alternate Phone
Website
Email
Email
How were you contacted?
How were you contacted:
Date you were contacted:
(mail, phone, email, etc.)
If you were called by phone, at which phone number did you receive the call(s)?
Is this telephone number registered on the National Do Not Call Registry?
Yes
No
Product or Payment Involved
(if any)
Product/Service Involved (if any):
Date of Your Payment (if any):
Method of Your Payment (if any):
(cash, credit card, debit card, wire transfer, reload pack, etc.)
Amount of Your Payment (if any):
Has this amount (if any) been refunded?
Yes
No
Minnesota Attorney General’s Office • 445 Minnesota Street, Suite 1400, St. Paul, MN 55101
Twin Cities Calling Area: (651) 296-3353 • Outside the Twin Cities: (800) 657-3787 • Minnesota Relay: (800) 627-3529
www.ag.state.mn.us
Fraud Report Form
The Office of the
Minnesota Attorney General
helping people afford their lives and live with dignity and respect
Information About You
Information About the Scammer
(if known)
Your Name
Suffix (Jr., Sr., etc.)
Name of Person or Entity
Street Address
Street Address
City, State, Zip
City, State, Zip
Primary Phone
Phone Number
Alternate Phone
Website
Email
Email
How were you contacted?
How were you contacted:
Date you were contacted:
(mail, phone, email, etc.)
If you were called by phone, at which phone number did you receive the call(s)?
Is this telephone number registered on the National Do Not Call Registry?
Yes
No
Product or Payment Involved
(if any)
Product/Service Involved (if any):
Date of Your Payment (if any):
Method of Your Payment (if any):
(cash, credit card, debit card, wire transfer, reload pack, etc.)
Amount of Your Payment (if any):
Has this amount (if any) been refunded?
Yes
No
Minnesota Attorney General’s Office • 445 Minnesota Street, Suite 1400, St. Paul, MN 55101
Twin Cities Calling Area: (651) 296-3353 • Outside the Twin Cities: (800) 657-3787 • Minnesota Relay: (800) 627-3529
www.ag.state.mn.us
Explanation of What Happened
Other Agencies You Contacted About This & Result
By signing below, I consent to and acknowledge that the information I am providing may be used and/or disseminated by the Minnesota
Attorney General’s Office: (a) to resolve the issue about which I am contacting the Office, including by contacting any person or entity
complained against; (b) to communicate with me; (c) to other law enforcement agencies and/or consumer-assistance agencies; and
(d) to otherwise assist in enforcing the law. Except as otherwise authorized by this consent, I understand that the information I am
providing will be treated as “private data on individuals” under the Minnesota Government Data Practices Act, Minn. Stat. ch. 13, and
shall not be used or disseminated except as authorized under the Act or other applicable state or federal law. I understand that I am
not legally required to provide the information I have submitted in this form, but that my failure to do so may make it more difficult to
resolve my concern.
Signature
Date
Please mail completed, signed form (and any attachments) to:
Office of Minnesota Attorney General Keith Ellison, 445 Minnesota Street, Suite 1400, St. Paul, MN 55101.
This document is available in alternative formats to individuals with disabilities by calling
(651) 296-3353 (Twin Cities Calling Area), (800) 657-3787 (Outside the Twin Cities), or through the Minnesota Relay Service at (800) 627-3529.
The Minnesota Attorney General’s Office values diversity and is an equal opportunity employer.
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