2. If this is an emergency or a crime in progress, do not use this form; instead call 911 immediately.
4. I Certify the Following: *

   1. This is NOT an emergency or a crime in progress; I understand that I may not receive a police response for as long as 3 business days.
6. First Name*
7. Last Name*
9. Date of Birth*
10. Telephone*
11. Email Address*
13. Home Address*
14. City*
16. State*
17. Zip*
21. Date of Online Fraud*
22. Time of Online Fraud*
24. Detailed Description of Online Fraud*
26. Estimated Value of Loss Due to Fraud*
28. Additional Comments
30. Within 3 business days of submitting this form, you should receive a case number and confirmation via email.
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32. Submit

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