FINANCIAL REGULATION FRAUD, THEFT, FORGERY, AND

Page 1 of 5Financial Regulaon Fraud, The, Forgery, and Convicons Reporng Form 07/2023

This Reporting Form has been issued by the Commissioner of Financial Regulation pursuant to COMAR

09.03.10.02. The full text of COMAR 09.03.10.02 is printed on the last page of this Reporting Form;

please review it carefully.

This Reporting Form may be used by regulated persons reporting pursuant to COMAR 09.03.10.02; it

may also be used by persons not regulated by the Commissioner to report alleged acts, or suspected

acts, of fraud, theft, or forgery, or convictions, of persons regulated by the Commissioner.

Instruc tio ns:

This is a fillable PDF form which means you may complete and sign this form electronically. If you decide to

complete the form manually, please print the form, print your information clearly and sign your name.

This is NOT an online form; you must submit your report by one of the means listed below. Be sure to

sign (electronically or manually) and date your report.

Deliver your completed report form and relating documents by one of the following methods:

FINANCIAL REGULATION

FRAUD, THEFT, FORGERY, AND

CONVICTIONS REPORTING FORM

BY E-MAIL:

CSU.Complaints@maryland.gov

BY MAIL:

Attention: Enforcement Unit

Office of Financial Regulation

1100 North Eutaw Street, Suite 611

Baltimore, Maryland 21201

IN-PERSON:

Appointments are available to hand-deliver documents or for virtual

meetings with Financial Regulation staff. To schedule an appointment

online, please visit the Office’s online scheduling system.

BY FAX:

Use the following fax number 410-333-0475

(Please mark your fax to the attention of the Enforcement Unit).

Page 2 of 5Financial Regulaon Fraud, The, Forgery, and Convicons Reporng Form 07/2023

Part I. Information Regarding Individual Filing Report (“Reporting Individual”)

Financial Regulation

Fraud, Theft, Forgery, & Convictions Reporting Form

Your Name

Mr. Ms.

Home Phone # Cell Phone # Work Phone # Fax #

Street Address City State Zip

Name of Regulated Business (if applicable):

Address of Regulated Business (if applicable) City State Zip

Before you submit or mail your form:

Proofread the information you have provided and make sure it is correct. Enclose copies (NOT ORIGINALS) of

documents that relate to your report. Please make sure to sign and date the form.

Part II. Suspected Acts of Fraud, Theft, or Forgery

The Reporting Individual shall provide the information requested below relating to the Reporting Individual’s

discovery that a suspected act of fraud, theft, or forgery has been committed by a regulated person, or any owner,

director, officer, member, partner, employee, or agent of a regulated person (including the Reporting Individual),

or has reason to believe that such an act been committed.

Identify the regulated person, or owner, director, officer, member, partner, employee, individual, or agent of the

regulated person who committed, or is believed to have committed, a suspected act of fraud, theft or forgery:

Date of Report

Page 3 of 5Financial Regulaon Fraud, The, Forgery, and Convicons Reporng Form 07/2023

Descripon or nature of the suspected act of fraud, the or forgery: (Aach addional pages or documentaon if necessary)

Name Title

Address/Locaon City State Zip

Date on or about the regulated person, or owner, director, ocer, member,

partner, employee, individual, or agent of the regulated person, commied, or is

believed to have commied, the suspected act of fraud, the, or forgery:

Date of the Reporng Individual’s discovery of

the suspected act of fraud, the, or forgery:

Page 4 of 5Financial Regulaon Fraud, The, Forgery, and Convicons Reporng Form 07/2023

Descripon or nature of the convicon: (Aach addional pages or documentaon if necessary)

Signature of Reporng Individual Date

Part IV. Signature

This Reporng Form is led pursuant to COMAR 09.03.10.02. The Reporng Individual reasonably believes that the informaon

contained herein is true and correct and the Reporng Individual took reasonable steps to verify its truth and accuracy.

Part III. Report of Convictions

Name Title

Idenfy the regulated person, or owner, director, ocer, member, partner, employee, individual, or agent

of the regulated person, who was convicted of any felony, or of a misdemeanor involving fraud, the, or forgery:

Address/Locaon City State Zip

Date that Reporng Individual

received knowledge of convicon

Date of convicon

Descripon of sentence/nes/restuon

Court which rendered verdict Case name and number

Page 5 of 5Financial Regulaon Fraud, The, Forgery, and Convicons Reporng Form 07/2023

Part V. Text of Regulation

A. Duty to Report.

1. Except as provided in §E of this regulaon, a regulated person shall submit a report to the Commissioner within 30

business days aer the person discovers that an act, or has reason to believe that an act, of fraud, the, or forgery

has been commied by a regulated person, including the person, or any owner, director, ocer, member, partner,

employee, or agent of a regulated person.

2. Except as provided in §E of this regulaon, a regulated person that is, or that has an owner, director, ocer, member,

partner, employee, or agent that is, convicted of any felony, or of a misdemeanor involving fraud, the, or forgery,

shall submit a report to the Commissioner informing the Commissioner of the convicon within 5 business days from

the date on which the regulated person receives knowledge of the convicon.

B. Contents of Report.

1. A regulated person subming a report pursuant to this regulaon shall ulize the reporng form prescribed by

the Commissioner.

2. If it is determined aer the submission of a report that informaon contained in the report is false or otherwise

inaccurate, the regulated person that submied the report shall be considered to be in compliance with the reporng

requirements of this regulaon if the regulated person reasonably believed that the informaon was true and

accurate at the me the report was submied and the regulated person took reasonable steps to verify its truth and

accuracy.

C. Nondisclosure of Report. A regulated person subming a report to the Commissioner pursuant to this regulaon

may not disclose to any person that is a subject of the report the existence of the report or that the report has been

submied to the Commissioner.

D. Reports to Law Enforcement Authories. Except as provided in §E of this regulaon, a regulated person that

discovers that an act, or suspected act, of fraud, the, or forgery required to be reported pursuant to this regulaon

has been commied, the regulated person shall report the details of the incident to the appropriate law enforcement

authories.

E. Excepons. The provisions of this regulaon do not apply to a bank, savings bank, trust company, or credit union

having a branch that accepts deposits in this State.

“Regulated person” means an individual, corporaon, business trust, nancial instuon, estate, trust, partnership,

associaon, two or more persons having a joint or common interest, or any other legal or commercial enty that is

subject to the regulatory authority of the Commissioner pursuant to Financial Instuons Arcle, or Commercial Law

Arcle, Annotated Code of Maryland. COMAR 09.03.10.01B(6).

COMAR 09.03.10 .02 Reporng Fraud, Other Violaons of Law, and Convicons.