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Online Fraud Reporting Form
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Type of Fraud
Impersonation (ID Theft)
What company or bank issued the credit card / check?
What is the card or account number?
Charge(s) occurred between:
Charge(s) occurred between: Start Date
Charge(s) occurred between: Start Time
Charge(s) occurred between: End Date
Charge(s) occurred between: End Time
Was the card / check in your possession at the time the charge(s) were made?
Name of Business and/or Address Where the Charge(s) Were Made
If you are not the victim making this report, what is your relationship to them?
Do you have additional Information about the suspect?
Personal Statement (Tell us what happened in your own words)
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