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Claimant Missing Check Incident Report

Question	Answer
PART I - to be completed by Claimant at the time he/she executes the Declaration of Forged Check Endorsement (DE 817D / DE 817DIS / DE 817F). PLEASE PRINT CLEARLY.
1. NameBlank space	2. For Office Use OnlyBlank space
3. Driver License/Identification Card NumberBlank space	4. Full Date of BirthBlank space
5. Current AddressBlank space	6. Phone NumberBlank space
7. Names of Other People Using This Same AddressBlank space	8. Is Address Above Same as Address of Checks? Yes NoNo
9. If address above is different than address of check, did you file a change of address with the Post Office?
Yes No If yes, approximate date: Blank line
10. Please check the box next to the true answer below and sign your name at the end of each line.
Did you receive this check?	Yes	No	Blank line
Did you lose this check after receiving it?	Yes	No	Blank line
Did you endorse this check after receiving it?	Yes	No	Blank line
Did you authorize anyone to sign or cash this check?	Yes	No	Blank line
11. Complete for Lost or Stolen Checks:
If check was stolen, did you report it?
Yes	No
If yes, to whom? Police - Name of Police Agency and Case # Blank line
Post Office Other: Blank line
Date Reported: Blank line
Additional comments (circumstances pertaining to the missing check) Blank line
Blank line
Blank line
Blank line
Claimant Signature Blank space	Date Blank space

PART I - to be completed by Claimant at the time he/she executes the Declaration of Forged Check Endorsement (DE 817D / DE 817DIS / DE 817F). PLEASE PRINT CLEARLY.

1. NameBlank space

2. For Office Use OnlyBlank space

3. Driver License/Identification Card NumberBlank space

4. Full Date of BirthBlank space

5. Current AddressBlank space

6. Phone NumberBlank space

7. Names of Other People Using This Same AddressBlank space

8. Is Address Above Same as Address of Checks?
Yes NoNo

9. If address above is different than address of check, did you file a change of address with the Post Office?

Yes No

If yes, approximate date:

Blank line

10. Please check the box next to the true answer below and sign your name at the end of each line.

Did you receive this check?

Yes

No

Blank line

Did you lose this check after receiving it?

Yes

No

Blank line

Did you endorse this check after receiving it?

Yes

No

Blank line

Did you authorize anyone to sign or cash this check?

Yes

No

Blank line

11. Complete for Lost or Stolen Checks:

If check was stolen, did you report it?

Yes

No

If yes, to whom?

Police - Name of Police Agency and Case # Blank line

Post Office Other: Blank line

Date Reported:

Blank line

Additional comments (circumstances pertaining to the missing check)

Blank line

Claimant Signature Blank space

Date Blank space

Question	Answer
PART II - to be completed by Departmental Representative after claimant has examined front and back of copy of missing check(s) and has executed Declaration(s) of Forged Check Endorsement (DE 817D / DE 817DIS / DE 817F).
1. Can claimant identify individual who signed his/her name as first endorsement?	Yes	No	If yes, answer below:
Name	Blank line	Relationship	Blank line
Address	Blank line	Phone Number	Blank line
2. Can claimant identify individual or entity who cashed this check (second endorser)?	Yes	No	If yes, answer below:
Name/Business	Blank line	Relationship	Blank line
Address	Blank line	Phone Number	Blank line
EDD REPRESENTATIVEBlank space	Telephone #Blank space	Office #Blank space	DateBlank space

PART II - to be completed by Departmental Representative after claimant has examined front and back of copy of missing check(s) and has executed Declaration(s) of Forged Check Endorsement (DE 817D / DE 817DIS / DE 817F).

1. Can claimant identify individual who signed his/her name as first endorsement?

Yes

No

If yes, answer below:

Name

Blank line

Relationship

Blank line

Address

Blank line

Phone Number

Blank line

2. Can claimant identify individual or entity who cashed this check (second endorser)?

Yes

No

If yes, answer below:

Name/Business

Blank line

Relationship

Blank line

Address

Blank line

Phone Number

Blank line

EDD REPRESENTATIVEBlank space

Telephone #Blank space

Office #Blank space

DateBlank space

DE 8784 Rev.9 (3-22) (INTRANET)

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UI / DE 8784

Claimant Missing Check Incident Report