Note: Fields marked with * are required.

Your Personal Information

Yes No

numbers only (1112223333)

Yes No

Yes No

Information about the Individual/Business that victimized you

numbers only (1112223333)

Other Identifiers about the Individual/Business that victimized you

Monetary Loss

$ (US Dollars) Enter 0 for no loss

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

Description of the Incident

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
In person
Internet messaging
Web site

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.

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).