Information About the Scam Means of Contact (Ex. Phone, Email, Mail) Type of Scam (Ex. Tech Support, IRS Scam Call, Identity Theft) Describe the Scam Personal Information Did you lose money? Yes No If yes, how much? Age 19 and Under20-2930-3940-4950-5960-6970+ Military (If applicable) Active Duty Veteran County Information About the Scammer Scammer Name Scammer Address City State Zip Phone Website Email Address Used Your Information Would you like us to contact you regarding this scam? Yes No Your First Name Required Your Last Name Required Address City State Phone Required Email Security Authentication Required
