Business Fraud Claim

Legal business name(Required)

Federal Tax ID number(Required)

DBA or alternative business name

Business Type(Required)

Business Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Main Office Phone Number(Required)

Information of person filing claim

Name(Required)

First Last

Your job title

Your office phone number(Required)

Your contact phone number(Required)

Your email address(Required)

I certify that I am authorized to speak on behalf of this Business.

Claim information

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?(Required)

Yes

No

Account number of the account to report as fraud(Required)

Account type(Required)

Wireless

Wireline/Landline

Fios

I don't know

Do you have legitimate FTC Accounts on which you are not making a claim?

Yes

No

Account number of your authorized FTC account (not filing a claim against)(Required)

Current address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Years at address(Required)

Prior address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Years at address

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.(Required)

Yes

No

Authorized by(Required)

Name(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)

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(Required)

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 business identity (Must pick ONE)(Required)

Article of Incorporation/Organization

Business License

Proof of business identity UPLOAD(Required)

Accepted file types: pdf, jpeg, png, gif, Max. file size: 50 MB.

Proof of Personal Identity(Required)

Accepted file types: pdf, jpeg, png, gif, Max. file size: 50 MB.

Employee ID or Pay Stub (Must pick ONE)(Required)

Employee ID

Pay Stub (less than 30 days old)

Employee ID or Pay Stub UPLOAD(Required)

Accepted file types: pdf, jpeg, png, gif, Max. file size: 50 MB.

Proof of Residency (Must pick TWO)(Required)

Non-FTC Utility Bill

Insurance Bill

Lease, Mortgage, or HUD

Proof of Residency UPLOAD(Required)

Drop files here or

Accepted file types: pdf, jpeg, png, gif, Max. file size: 50 MB, Max. files: 2.

Police report UPLOAD(Required)

Accepted file types: pdf, jpeg, png, gif, Max. file size: 50 MB.

Additional information

Accepted file types: pdf, jpeg, png, gif, Max. file size: 50 MB.

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