Complaint Form - Internet Crime Complaint Center (IC3)

Who is Filing this Complaint?
Complainant Information
Financial Transaction(s)
Information About The Subject(s)
Description of Incident
Other Information
Privacy & Signature

A red asterisk (*) indicates a required field.
All other fields are optional. Please provide all requested information if possible, but these fields may be left blank.
Do not not provide complainant Personally Identifiable Information (PII) such as Social Security numbers or dates of birth anywhere in this form.

Who is Filing this Complaint?

If you were the one affected by this incident, please indicate so below. In the event that you are completing this form on behalf of another individual or business, please select NO and provide your contact information.

*Were you the one affected in this incident?

Yes No

Your Contact Information

*Name:

Business Name:

*Phone Number:

*Email Address:

Complainant Information

Please provide as much detail as possible related to the one affected by this incident. If you are reporting on behalf of a business, please include any Points-of-Contact (POCs) at the business in the section below.

*Name:

Age:

*Is the complainant 17 years old or younger?

Yes No

*Address:

Address (continued):

Suite/Apt./Mail Stop:

*City:

County:

*Country:

*State:

*Zip Code/Route:

*Phone Number:

*Email Address:

Business Information

Is this on behalf of a business that was targeted by a Cyber incident?

Yes No

*Business Name:

*Is the incident currently impacting business operations?

Yes No

Business IT POC:

Other Business POC:

If your business or organization is defined as a critical infrastructure entity, select the sector below:

If known or applicable, please select the critical infrastructure subsector:

Financial Transaction(s)

*Did you send or lose money in the incident?

Yes No

*What was your total loss amount?

For the transaction information below:

Provide the most recent transactions involved with this incident.
Specify all money amounts below in US Dollars (USD).
Originating account refers to where the funds were sent from; usually the Complainant's account.
Recipient account refers to where the funds were sent to; usually a Subject's account.
More information about the types of transactions can be found by clicking the help icon next to the Transaction Type field.

Transaction Type:

*If other, please specify:

*Was the money sent or lost?

Yes No

*Transaction Amount:

*Transaction Date:

Did you contact your bank, financial institution, or cryptocurrency exchange?

Yes No

Originating Bank Name:

Originating Bank Address:

Originating Bank Address (cont.):

Originating Bank Suite/Mail Stop:

Originating Bank City:

Originating Bank Country:

Originating Bank State:

Originating Bank Zip Code/Route:

Originating Name on Account:

Originating Account Number:

Type of Cryptocurrency:

P2P Application Used:

Transaction ID/Hash:

Cryptocurrency ATM/Kiosk:

Type of Prepaid/Gift Card:

ATM/Kiosk Address:

ATM/Kiosk City:

ATM/Kiosk Country:

ATM/Kiosk State:

ATM/Kiosk Zip Code/Route:

Originating Wallet Address:

Originating Account Identifier:

Prepaid/Gift Card Number:

Recipient Bank Name:

Recipient Bank Address:

Recipient Bank Address (cont.):

Recipient Bank Suite/Mail Stop:

Recipient Bank City:

Recipient Bank Country:

Recipient Bank State:

Recipient Bank Zip Code/Route:

Recipient Name on Account:

Recipient Name:

Recipient Bank Routing Number:

Recipient Account Number:

Recipient Bank SWIFT Code:

Recipient Wallet Address:

Recipient Account Identifier:

Recipient Identifier (email/phone):

Information About The Subject(s)

Name:

Business Name:

Address:

Address (continued):

Suite/Apt./Mail Stop:

City:

Country:

State:

Zip Code/Route:

Phone Number:

Email Address:

Website/Social Media Account:

IP Address:

Description of Incident

Law enforcement or regulatory agencies may desire copies of pertinent documents or other evidence regarding your complaint. Originals should be retained for use by law enforcement agencies. It is not necessary to provide your evidence here.

*Describe what happened in your own words. Provide any information you have yet to include in this complaint that may assist law enforcement in understanding what happened.

Please limit responses to 3,500 characters

Other Information

Please provide any technical details regarding this incident. This can include email headers, cryptocurrency transaction metadata, ransomware hashes, etc.

Please limit responses to 5,000 characters

Are there any other witnesses or persons affected by this incident?

Please limit responses to 1,000 characters

If you have reported this incident to other law enforcement or government agencies, please provide the name, phone number, email, date reported, report number, etc.

Please limit responses to 1,000 characters

Is this an update to a previously filed complaint?

YesNo

Privacy & Signature

Read the following statement below, and confirm your agreement by typing your full name below in the box provided:

The collection of information on this form is authorized by one or more of the following statutes: 18 U.S.C. § 1028 (false documents and identity theft); 1028A (aggravated identity theft); 18 U.S.C. § 1029 (credit card fraud); 18 U.S.C. § 1030 (computer fraud); 18 U.S.C. § 1343 (wire fraud); 18 U.S.C 2318B (counterfeit and illicit labels); 18 U.S.C. § 2319 (violation of intellectual property rights); 28 U.S.C. § 533 (FBI authorized to investigate violations of federal law for which it has primary investigative jurisdiction); and 28 U.S.C. § 534 (FBI authorized to collect and maintain identification, criminal information, crime, and other records).

The collection of this information is relevant and necessary to document and investigate complaints of Internet-related crime. Submission of the information requested is voluntary; however, your failure to supply requested information may impede or preclude the investigation of your complaint by law enforcement agencies.

The information collected is maintained in one or more of the following Privacy Act Systems of Records: the FBI Central Records System, Justice/FBI-002, notice of which was published in the Federal Register at 63 Fed. Reg. 8671 (Feb. 20, 1998); the FBI Data Warehouse System, DOJ/FBI-022, notice of which was published in the Federal Register at 77 Fed. Reg. 40631 (July 10, 2012). Descriptions of these systems may also be found at www.justice.gov/opcl/doj-systems-records#FBI. The information collected may be disclosed in accordance with the routine uses referenced in those notices or as otherwise permitted by law. For example, in accordance with those routine uses, in certain circumstances, the FBI may disclose information from your complaint to appropriate criminal, civil, or regulatory law enforcement authorities (whether federal, state, local, territorial, tribal, foreign, or international). Information also may be disclosed as a routine use to an organization or individual in both the public or private sector if deemed necessary to elicit information or cooperation from the recipient for use by the FBI in the performance of an authorized activity. "An example would be where the activities of an individual are disclosed to a member of the public in order to elicit his/her assistance in [FBI's] apprehension or detection efforts." 63 Fed. Reg. 8671, 8682 (February 20, 1998).

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature. I affirm that the information I provided is true and accurate to the best of my knowledge. I understand that providing false information could make me subject to fine, imprisonment, or both. (Title 18, U.S.Code, Section 1001)

*Digital Signature:

Confirm Action

Transaction Type Definitions

Routing Number Definition

SWIFT Code Definition

Peer-to-peer Account Identifiers

Type of CryptoCurrency

Transaction ID/Hash

Cryptocurrency ATM/Kiosk

ATM/Kiosk Address

Originating Wallet Address

Recipient Wallet Address

Type of Prepaid/Gift Card

Terms and Conditions