Report Mortgage Fraud Form

To submit suspicions of mortgage fraud to the Grand Rapids Association of REALTORS� for consideration, please complete the following form to the best of your ability. Please note that the information that you provide may be forwarded to other authorities for investigation.

Notes:	Required fields are marked with and asterisk (*)
	If there are more participants, please include the additional names and contact information in the summary section below

SUSPECT(S) INFORMATION
Last Name or Name of Entity*
First Name*
Middle Initial
Business Address*
City*
State*
Zip*
Phone (example 616-940-8200)*
Member of the Grand Rapids Association of REALTORS�*	Yes No Don't Know

TYPE OF FRAUD
Select one or more *	Disappearing Second Mortgage
	Equity Skimming
	Foreclosure Rescue
	Inflated Appraisal
	Occupancy Fraud
	Property Flipping
	Silent Second Mortgage
	Property Flopping
	Buy and Bail
	Other

DATE OR RANGE OF SUSPICIOUS ACTIVITY
From*
To*

TOTAL DOLLAR AMOUNT INVOLVED (example 1,000)
Amount*

PLEASE SUMMARIZE THE EVENTS OR THE TRANSACTION (OPTIONAL)

HAS THIS INFORMATION BEEN REPORTED TO ANOTHER AGENCY?
Select one*	Yes No Don't Know
If yes, please identify	Attorney General
	Department of Labor and Economic Growth (DLEG - State Licensing Departement)
	Federal Bureau of Investigations (FBI)
	Department of Housing and Urban Development (HUD)
	Internal Revenue Service (IRS)
	Michigan Association of REALTORS� (MAR)
	Office of Finance & Insurance (OFIS)
	Other

SUPPORTING DOCUMENTATIONS (if any)
Check which documents you will be providing. Then fax documents to (616) 940-8216	Listing Agreement
	Purchase Agreement
	Closing Agreement
	Appraisal
	Other

YOUR CONTACT INFORMATION (optional)
Last Name
First Name
Company Name (if applicaple)
Street Address
City
State
Zip
Phone (example 616-940-8200)
E-mail