Report to help fight fraud! Protect your community by reporting fraud, scams, and bad business practices. First Name Middle Name Last Name Date of Birth Email Cell Phone Alternet Phone Home Phone Address Suite/Apt # City State Alabama - AL Alaska - AK Arizona - AZ Arkansas - AR California - CA Colorado - CO Connecticut - CT Delaware - DE Florida - FL Georgia - GA Hawaii - HI Idaho - ID Illinois - IL Indiana - IN Iowa - IA Kansas - KS Kentucky - KY Louisiana - LA Maine - ME Maryland - MD Massachusetts - MA Michigan - MI Minnesota - MN Mississippi - MS Missouri - MO Montana - MT Nebraska - NE Nevada - NV New Hampshire - NH New Jersey - NJ New Mexico - NM New York - NY North Carolina - NC North Dakota - ND Ohio - OH Oklahoma - OK Oregon - OR Pennsylvania - PA Rhode Island - RI South Carolina - SC South Dakota - SD Tennessee - TN Texas - TX Utah - UT Vermont - VT Virginia - VA Washington - WA West Virginia - WV Wisconsin - WI Wyoming - WY Zip Have you been a victim of Identity Theft before? Yes No Did you ever disclose your SSN information in the past? Yes No Please provide your full Social Security Number (SSN) so we can verify any past identity theft cases related to you. Driver's License # Do you drive yourself in case if you have to visit one of our offices? Yes No How did you become aware of the identity fraud situation? Tech Company (Microsoft Support, Apple Support, AMAZON, Banking Institution) I have been contacted by a Federal Agencies ( FTC,FBI, US Department of Treasury, SSA, DEA etc.) None of Above What is your usual method of accessing your bank accounts? Online Banking Offline Banking (Visiting Branch in person) Do you have someone who handles your banking or financial advisor? Yes No Which banks or financial institutions do you have Checking or Savings accounts at? (Please list all institutions, both domestic and international.) If you have joint accounts, please list the names of the other account holders. Are you currently holding investments with any financial institutions? (This includes IRA, 401K, CDs, Money Market, Pension Funds, and other bonds.) If so, please list the names. What kind of cellphone do you use? Android Apple No Cellphone Are you having any disability or medical conditions? Yes No Are your aware about Cryptocurrencies or have your ever dealt with Cryptocurrencies? Yes No Agree, that we will request some of your personal Information in order to create a complaint form that will be submitted to IC3, FCC and CONSUMER FINANCIAL PROTECTION BUREAU. Submit
