Security Paper
Damage and Problem Report
OFFICE OF VITAL RECORDS
Instructions: Use this form to report problems about vital record security paper for your office.
Complete the report and send it to the Office of Vital Records by email [email protected]
or by fax to 651-201-5740. Please note “Damage and Problem Report” in the subject line or comments.
Provide as much information as possible to adequately address and resolve the problem.
ISSUANCE OFFICE INFORMATION
Office Location:
Location Code:
Name of person reporting the problem:
Telephone:
Email:
DESCRIPTION OF THE PROBLEM
Partial shipment 
Paper missing from box 
Damaged in shipping 
Delivery problem 
Paper quality 
Fraud 
Theft 
Printing problem 
Other:
DETAILS AND ACTION TAKEN
Describe problem or incident in chronological order. Attach additional page if needed.
Provide information about anyone who was involved or who observed the incident. Please print clearly.
Witness Name:
Telephone:
Did you notify law enforcement? N/A  No  Yes  If yes, by whom?
Police Department:
Police Report No:
Name of Police Officer:
Telephone:
Employee’s Signature:
Date:
Supervisor’s Signature:
Date:
REQUEST FOR RESOLUTION
If unclear from above, describe the action you want the Office of Vital Records to take to resolve the problem.
10/28/2015