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: Complaint Input Form

OMB #
3084-0047

Complaint Input Form

If you believe you have been the victim of identity theft, you may use the form below to send a complaint to the Federal Trade Commission (FTC). The information you provide is up to you. However, if you don't provide your name or other information, it may be impossible for us to refer, respond to, or investigate your complaint or request. To learn how we use the information you provide, please read our Privacy Policy.

The FTC serves as the federal clearinghouse for complaints by victims of identity theft. While the FTC does not resolve individual consumer problems, your complaint helps us investigate fraud, and can lead to law enforcement action. The FTC enters Internet, telemarketing, identity theft and other fraud-related complaints into Consumer Sentinel®, a secure, online database available to hundreds of civil and criminal law enforcement agencies worldwide.

We use secure socket layer (SSL) encryption to protect the transmission of the information you submit to us when you use our secure online forms. The information you provide to us is stored securely.

If you want to file a complaint with the FTC about a problem other than identity theft, please use the Federal Trade Commission online complaint form.

How Do We Reach You?

First Name:
Last Name:
Street Address:
Apt. or Suite No.:
City:
State/Province:
Zip: -
Country:

Home Phone:()
(Area Code)(Phone Number)
(Numbers Only)
Work Phone: Ext.
(Area Code)(Phone Number)(Extension)
(Numbers Only)
Social Security Number: - - Date Of Birth:(MM/DD/YYYY)

Email Address:(i.e., anyone@myisp.com)

Tell Us About Your Problem

1. Types of Identity Theft You Have Experienced.

ID Theft occurs when someone uses your name or other identifying information for their personal gain. Please check the types of ID theft you were a victim of. (Check as many as apply)

Credit CardsSecurities or Other Investments
Checking or Savings AccountsInternet or E-Mail
LoansGovernment Documents or Benefits
Phone or UtilitiesOther

Did suspect use the Internet to open the account or purchase the goods or services? Yes
No
Don't Know

2. Describe Your Complaint Here.

Please give us information about the identity theft, including, but not limited to, how the theft occurred, who may be responsible for the theft, and what actions you have taken since the theft. Please include a list of companies where fraudulent accounts were established or your current accounts were affected. Please limit your complaint to 2000 characters.

3. Details of the Identity Theft.

When did you notice that you might be a victim of identity theft?(MM/DD/YYYY)
When did the identity theft first occur? (i.e., when was the first account opened?)(MM/DD/YYYY)
How many accounts (credit cards, loans, bank accounts, cellular phone accounts, etc.) were opened or accessed?
How much money, if any, have you had to pay?
(Numbers Only)
How much money, if any, did the identity thief obtain from companies in your name?
(Numbers Only)

What other problems, if any, have you experienced as a result of the identity theft? (Click on the down arrow. To select more than one, hold down the CTRL key while clicking your selection)

4. The Identity Thief.

Please provide any information you may have about the identity thief, including his or her name, and any addresses or phone numbers the identity thief may have used.

First Name:
Last Name:
Street Address:
Apt. or Suite No.:
City:
State/Province:
Zip: -
Country:
Phone Number:()(Area Code)(Phone Number)
(Numbers Only)
Email Address:(i.e., anyone@myisp.com)
Your relationship to the identity thief:

5. Contacts.

Please indicate which of the following steps, if any, you have already taken to deal with the identity theft.
For which of the following credit bureaus, have you: (check all that apply)

Called to report the fraud?: Equifax Experian Trans UnionOtherNone
Put a "fraud alert" on your report?: Equifax Experian Trans UnionOtherNone
Ordered your credit report?: Equifax Experian Trans UnionOtherNone
Problem with Credit Bureau?: Equifax Experian Trans UnionOther

Have you Contacted the police? Yes
No
If yes, please provide police department name:
Department State:
Report Number? Yes
No
If yes, please provide report number:

6. Problems with Companies.

Do you have any problems with the companies, credit bureaus, or organizations you are dealing with concerning your identity theft problems? If so, identify each company, credit bureau, or organization, provide its location and/or telephone number, if you have it, and tell us briefly what the problem is.
NOTE: If you checked the problem box for any of the three credit bureaus in the section above, please include those credit bureaus here.

Company 1

Company Name:
City:
State/Province:
Zip: -
Country:
Phone Number:() Ext. (Area Code)(Phone Number)(Extension)
(Numbers Only)
Have you notified this company? Yes
No
Have you sent written notifications to this company? Yes
No

Company 2

Company Name:
City:
State/Province:
Zip: -
Country:
Phone Number:() Ext. (Area Code)(Phone Number)(Extension)
(Numbers Only)
Have you notified this company? Yes
No
Have you sent written notifications to this company? Yes
No

Company 3

Company Name:
City:
State/Province:
Zip: -
Country:
Phone Number:() Ext. (Area Code)(Phone Number)(Extension)
(Numbers Only)
Have you notified this company? Yes
No
Have you sent written notifications to this company? Yes
No

Paperwork Reduction Act Statement: This form is designed to improve public access to the FTC's Bureau of Consumer Protection's Consumer Response Center, and is voluntary. Through this form, consumers may electronically register a complaint with the FTC. We estimate that it will take, on average, 5 minutes to complete the form. Under the Paperwork Reduction Act, as amended, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. That number is 3084-0047, which also appears in the upper right-hand corner of the first page of this form.