Complaint Referral Form

Internet Crime Complaint Center

Note: Fields marked with * are required.

Your Personal Information

* First Name: First Name is required

Middle Name: Middle Name - invalid input

* Last Name: Last Name is required

Business Name: Business Name - invalid input

* Age:

* Gender:

* Address: Address is required

Address (continued): Address continued - invalid input

Suite/Apt./Mail Stop: Suite/Apt./Mail Stop - invalid input

* City:

Do you live within the city limits?: Yes No
County:
State:
* Country: Country is required

* Zip Code / Route: Zip Code is required

* Phone Number: Phone is required

numbers only (1112223333)
* Email Address: Email Address is required

jdoe@email.com

Name of your local police or sheriff's office:

Is the complaint you are filing related to the Internet or an online service?
(email, chat, instant message, AOL, MSN, Yahoo, etc.)
Yes No

Do you have pertinent documents in paper form?
Yes No

Law enforcement or regulatory agencies may desire copies of pertinent documents regarding your complaint. These may include cancelled checks, copies of money orders, printed emails, envelopes (if you should receive anything by FedEx, UPS, U.S. Mail, etc.), etc.

Original documents should be retained for use by law enforcement agencies.

Information about the Individual/Business that victimized you

Business Name: invalid input

First Name: invalid input

Middle Name: invalid input

Last Name: invalid input

Gender:
Address: invalid input

Address (continued): invalid input

Suite/Apt./Mail Stop: invalid input

City:

State:
Country:
Zip Code / Route: invalid input

Phone Number: invalid input

numbers only (1112223333)
Email Address: invalid input

jdoe@email.com

Other Identifiers about the Individual/Business that victimized you

Web Site:
IP Address:
IRC Server:
Chat Room Name:
Usenet Newsgroup:
Other:

Monetary Loss

* Please specify the total dollar amount of your loss from this incident:
$ (US Dollars) Enter 0 for no loss Amount Lost is required

Please indicate the means of payment (select all that apply):
Cash
Cashier's Check
Check/Debit Card
Credit Card
Money Order
Wire Transfer
Other (Specify Other)
Did you use a third party online payment service such as PayPal, BidPay, Escrow?
Yes No

Description of the Incident

* Describe in your own words how you have been victimized. Incident Description is required

Be specific. Include date(s) of transaction(s), a description of any items that were not delivered or were counterfeited, any transaction numbers (from Ebay, Western Union, PayPal, etc.), and any other pertinent information that helps to explain how you were victimized. Also if you received anything by U.S. Mail, FedEx, or UPS, specifically describe the envelope, by the date, time, city and zip code shown on the stamp cancellation postmark.

Please indicate any medium used by the individual/business in the course of the incident.
(select all that apply):
Bulletin board
Chat room
Email
Fax
In person
Internet messaging
Mail
Newsgroup
Telephone
Web site
Wire
Other

Please indicate the initial means of contact with the individual/business that victimized you:

Was this initial means of contact unsolicited/uninvited?
Yes No
What was your relationship with the individual/business you are complaining about prior to the incident you are reporting?

Did you conduct any research on the individual/business prior to the incident?
Yes No
How much time has passed since you determined you were victimized?
(select the best approximation)

Contact Information

Are there witnesses or other victims to this crime?
If yes, Please provide names, addresses, phone numbers, email addresses, and/or websites of where additional victim lists can be found.
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Have you reported this crime to any law enforcement or government agencies?
If yes, please indicate the organizations/individuals that you contacted (select all that apply)
Better Business Bureau
Consumer protection agency
Individual/business that victimized you
Police/other law enforcement
Private attorney

Provide the specific name of each organization, contact name, contact phone number, email address, date reported, and report number (if known).

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