REPORT CYBER CRIME

ALERT: If you think your life is in danger, please contact your local and/or state law enforcement immediately! This form is intended to be used as a tool to collect information regarding your experiences with cyber crime. We would like you to share with us stories and incidents about cyber crime. However, if you have been a victim of identity theft or an online predator and would like to report this crime, please report these crimes to appropriate links here:

• FBI & The National White Collar Crime Center (NW3C)
• United States Computer Emergency Readiness Team
• File a complaint with the Federal Trade Commission (1-877-IDTHEFT)
• Reporting agencies for placing fraud alerts:
  • www.equifax.com
  • www.experian.com
  • www.transunion.com

Your Information:
First Name: (required)
Last Name:
E-mail Address: (required*)
Street Address:
City:
State:
Zip Code:
Telephone Number:
Gender:	Male        Female
Age:	Please select one Under 20 20-29 30-39 40-49 50-59 60 or over
How did you hear about us?
(required) Year of Birth:	(ex. YYYY) In accordance with federal privacy laws. Not saved or used for marketing or promotion. Learn More.
(required) Code:	Load New Code Enter word from above
About the Incident:
Approximate Date and Time of Incident:
Type of Incident: (required)	Internet harassment (e.g. cyber bullying, cyber stalking) Spam e-mail Phishing e-mail Online identity theft Internet fraud Computer intrusion (e.g. hacking, viruses, spyware) Child pornography or exploitation Unsolicited obscene material sent to a child Online enticement of children for sexual acts Other Please specify:
Location of Incident (e.g. home or office):
Does your situation involve any real life contact?	Yes        No
Where did the incident take place? (required)	Bulletin Board/ News Group E-mail Yahoo! Messenger AOL Instant Messenger MSN Messenger Internet Relay Chat MySpace Facebook Other Please specify:
Screen/User name or email of the perpetrator:
Apparent gender of the perpetrator:	Male        Female        Not Sure
Do you know the perpetrator personally?	Yes        No        Not Sure
Do you believe the perpetrator knows enough of your personal information to be able to determine your identity or actual location?	Yes        No        Not Sure
Please describe the cyber crime incident in as much detail as possible: (required)