FTC Bureau of Consumer Protection - Consumer Information

Please Review Your Complaint

My Information

First Name:

Last Name:

Street Address:

Apt/PO Box:

City:

State:

Zip:

Country:

Lived Here Since (mm/dd/yyyy):

* *

Phone Number:

Date of Birth:

* *

Work Number:

Extension:

Cell Number:

Driver License Number:

State:

Social Security Number:

Why does FTC collect SSN?

Email Address:

Did you live at your current address at the time the fraud occurred?

Yes

My Information at the Time of the Fraud

Identity Theft Type Information

What kind of account was used or opened:	*
When was the account used or opened?	* *	How much did the suspect obtain:	$ .00 *
Account#:		Routing#:
Affected Check #s:
Company Name:
Company Address:
Apt/Suite/PO Box:
City:		State:
Zip:		Country:
Contact:
Company Phone Number:		Extension:
Company Email Address:	*
Company Website:	*

Police Department Information

Additional Information

Additional Information:

You have entered 708 of your 3500 available characters.

Please check the information that you have provided. Please Check the 'Checkbox' corresponding to the address and Click 'Accept' button to accept our recommended address or Click 'Reject' button if changes not required.
	Suggested Address	Entered Address
Consumer Address:	3803 Hanover St \|\|Madison\|WI\|53704	3803 Hanover Street\|\|Madison\|WI53704