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Were you the victim in this incident?
YES
NO
Name
Age
Address
Address (continued)
Suite/Apt./Mail Stop
City
County
Country
State
Zip Code/Route
Phone Number
Email Address
Is the victim a business that was targeted by a Cyber incident?
Business Name
Is the incident currently impacting business operations?
Business IT POC, if applicable
Other Business POC, if applicable
Transaction Type
If other, please specify
Was the money sent?
Transaction Amount
Transaction Date
Victim Bank Name
Victim Bank Address
Victim Bank Address (continued)
Victim Bank Suite/Mail Stop
Victim Bank City
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Victim Bank State
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Victim Name on Account
Victim Account Number
Recipient Bank Name
Recipient Bank Address
Recipient Bank Address (continued)
Recipient Bank Suite/Mail Stop
Recipient Bank City
Recipient Bank Country
Recipient Bank State
Recipient Bank Zip Code/Route
Recipient Name on Account
Recipient Bank Routing Number
Recipient Account Number
Recipient Bank SWIFT Code
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.
Name
Business Name
Address
Address (continued)
Suite/Apt./Mail Stop
City
Country
State
Zip Code/Route
Phone Number
Email Address
Website
IP Address
Privacy & Signature
Read the following statement below, and con rm 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 identi cation, 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). The information collected may be disclosed in accordance with the routine uses referenced in those notices or as otherwise permitted by law. In accordance with those routine uses, the FBI may disclose information from my complaint to appropriate federal, state, local, tribal or international law enforcement and regulatory agencies.
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