Figure: 7 TAC §91.610(g)

REPORT OF DEFACED OR ALTERED ROUTING NUMBER ON SAFE DEPOSIT BOX KEY

INSTRUCTIONS: Complete the information below and submit the original report to Department of Public Safety, Attn: Criminal Law Enforcement, Box 4087, Austin, Texas 78773-0001, no later than 10 days after the defaced or altered key is used to access the box. Retain one copy for your files for a period of three years.

CREDIT UNION INFORMATION

Name of credit union ____________________________________

Address of safe deposit box facility _________________________

______________________________________________________

Name and title of contact person at facility ___________________

______________________________________________________

Area code and phone number of facility _____________________

Routing number and branch designation (if any) _______________

INCIDENT INFORMATION

Member name _________________________________________

Date member presented defaced or altered key ________________

Description of problem with key ___________________________

______________________________________________________

______________________________________________________

Date of reports: _________________________

Exhibit A