Michigan Department of Treasury



Michigan Department of Treasury

4350 (Rev. 5-06)

CEPAS Incident Report

PART 1: CONTACT INFORMATION

|1. Name |2. Incident Report Number |

|      |      |

|3. Office Telephone Number |4. Emergency Contact Number |

|      |      |

|5. E-mail Address |6. Fax Number |

|      |      |

|7. Alternate Contact Name |8. Alternate’s Telephone Number |

|      |      |

PART 2: INCIDENT INFORMATION

|Incident Category |

| |

|Downtime Settlement Weakness in Internal Controls |

| |

|Duplicates Unauthorized/Unlawful Activity Other:       |

|Date of Incident |Date Incident Discovered |

|      |      |

|Incident Location |

|      |

|Involved Parties/Entities |

|      |

|Description of Incident |

|      |

|Date of Initial Report |

|      |

PART 3: INCIDENT RESOLUTION

|Action Taken |

|      |

|Incident Impact |

|      |

|Post Incident Recommendations |

|      |

|Date of Final Report |

|      |

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