Consumer Fraud Claim Δ Step 1 of 4 25% Name(Required) First Last Preferred NameDate of Birth (mm/dd/yyyy)(Required) MM slash DD slash YYYY Social Security Number(Required)How were you made aware of fraudulent account?(Required) Credit inquiry Collection notice Denial of service Other Do you know the account number of the account you are reporting as fraud?This can be obtained from your credit or collection report. Yes No Account number of the account to report as fraud(Required)Account type(Required) Wireless Wireline/Landline Fios I don’t know Enter contact informationHome phone number(Required)Mobile phone numberEmail address(Required) Current Address(Required) Street address Apt./Suite/Floor City State / Province / Region Zip Code Years at address(Required)Select years at address1-56-1011-1516-2021-2525+Prior address Street address Apt./Suite/Floor City State / Province / Region Zip Code Years at addressSelect years at address1-56-1011-1516-2021-2525+ 1) Did you authorize anyone to use your name or personal information in order to obtain the money, credit, loans, goods or services described in this report? This can include Power of Attorney or family member. Yes No Authorized by(Required)Select Authorized byPower of AttorneyFamily MemberOtherName(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Best contact phone number(Required)2) Did you receive any benefit, money, goods or services as a result of the events described in this claim?(Required) Yes No 3) Have your identification documents (credit cards, birth certificate, driver's license, Social Security Card etc.) been stolen or lost? If so, when?(Required) Yes No Date(Required) MM slash DD slash YYYY 4) Are you aware of a person that may have used your identifying information or identification documents to obtain money, credit, loans, goods or services with or without your consent? If yes, please indicate whom.(Required) Yes No Name(Required) First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Best contact phone number(Required)5) I am willing to work with law enforcement if/when charges are brought against the person(s) who committed the fraud.(Required) Yes No 6) I authorize the release of this information for the purpose of assisting law enforcement in a legal investigation and prosecution of the person(s) who committed this fraud.(Required) Yes No 7) I have reported the above events to local law enforcement. Please include report number/ID and reporting agency.(Required) Yes No Report number/ID(Required)Reported To(Required)Additional Details Document upload Documents may be in any of the following formats: pdf, jpeg, png or gif file.Proof of identity (Must pick ONE)(Required) State Issue Photo ID (Driver’s License, State ID) US Passport with photo Federal ID with photo Proof of Identity Upload(Required)Accepted file types: pdf, png, jpeg, gif, Max. file size: 50 MB. Proof of Residency (Must pick TWO)(Required) Non-FTC Utility Bill Insurance Bill Lease, Mortgage, or HUD Non-FTC Utility Bill, Insurance Bill and Lease, Mortgage, or HUD.Proof of Residency Upload(Required)Multiple files allowed Drop files here or Select files Accepted file types: pdf, jpeg, png, gif, Max. file size: 50 MB, Max. files: 2. Police report(Required)Accepted file types: pdf, jped, png, gif, Max. file size: 50 MB. Additional informationAccepted file types: pdf, jpeg, png, gif, Max. file size: 50 MB. CAPTCHA
