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Form For Reporting Fraud to SAMA

No: GDFCC-381000103246-1438H Date(g): 13/7/2017 | Date(h): 19/10/1438

Effective from 2018-01-09 - Jan 08 2018
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Form For Reporting Fraud to SAMA

a. Company Informationb.
Name   

Line of

Business

   
Headquarters City   

Name of Branch (if any)

 

 City   
Telephone No.   
E-mail   

 

c. Information on Fraud Incident

Date of

Incident

 
Total Amount (if any)

in words

SAR

in numbers

SAR

Fraud Incident Description 
Actions Taken 
Subsequent Actions 

 

d. Information on Alleged Fraudster

Name(s) 
ID/ Iqama No. 
Nationality 

  

e. Attached Documents

Report Writer 
Signature Date