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2. If you need immediate assistance, please call the main number at 860-886-5561 Ext. 6. If this is an emergency, please call 911. If you wish to report activity that is on-going and does not require immediate attention, please complete the form below.
   (Warning: Internet IP addresses are captured when submitting this form. Intentionally completing a form with false information can result in a criminal investigation)
6. Identity Theft Victim Information
8. First Name*
9. Middle Initial
10. Last Name*
11. Suffix
13. Date of Birth*
    Date of Birth
14. Sex*
    -- Select One --FemaleMaleUnknown
15. Race*
    -- Select One --AsianBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslandUnknownWhite
16. Ethnicity*
    -- Select One --Hispanic OrginNot of Hispanic Orgin Unknown
18. Social Security Number*
19. Phone Number*
20. Email*
21. Preferred method of communication*

    1. Email
    2. Telephone
23. Address*
25. City*
26. State*
27. Zip*
29. How Long have you lived at the above address?*
31. If applicable list previous address and years residing at those locations (seperate by comma)
33. Current Empolyer Information
35. Business Name (If unemployed, enter N/A)*
37. Address
39. City
40. State
41. Zip
43. Phone Number
44. Years Employed
46. Previous Employers if Applicable to report
50. Nature of Complaint*

    Check Appropriate Box

    1. Application for credit or loan
    2. Debit, checking or savings accounts
    3. Employment or taxes
    4. Government benefits or ID
    5. Loan or leases
    6. Other
52. If other, please explain
54. Fraudulent Account #1
56. Name Institution*
58. Account Type*

    1. Credit
    2. Bank
    3. Phone/Utilities
    4. Loan
    5. Government Benefits
    6. Other
59. Select ONE*

    1. This Account was opened fraudulently
    2. This Account was an existing account that someone tampered with
61. Account Number
62. Total Amount Obtained ($)*
64. Contact Person
65. Phone Number
67. Date Opened*
    Date Opened
68. Date Discovered*
    Date Discovered
69. Has this account been closed?*

    1. Yes
    2. No
71. Additional Information
73. Fraudulent Account #2 (If applicable)
75. Name of Institution
77. Account Type

    1. Credit
    2. Bank
    3. Phone/Utilities
    4. Loan
    5. Government Benefits
    6. Other
78. Select ONE

    1. This Account was opened fraudulently
    2. This Account was an existing account that someone tampered with
80. Account Number
81. Total Amount Obtained ($)
83. Contact Person
84. Phone Number
86. Date Opened
    Date Opened
87. Date Discovered
    Date Discovered
88. Has this account been closed?

    1. Yes
    2. No
90. Additional Information
92. Fraudulent Account #3 (If applicable)
94. Name of Institution
96. Account Type

    1. Credit
    2. Bank
    3. Phone/Utilities
    4. Loan
    5. Government Benefits
    6. Other
97. Select ONE

    1. This account was opened fraudulently
    2. This aacount was an existing account that someone tampered with
99. Account Number
100. Total Amount Obtained ($)
102. Contact Person
103. Phone Number
105. Date Opened
     Date Opened
106. Date Discovered
     Date Discovered
107. Has this account been closed?

     1. Yes
     2. No
109. Additional Information
113. Have you filed an Identity Theft report via identytheft.gov?*

     1. Yes
     2. No
114. If yes, what is your case number?
116. Images or supporting documents
120. By completing this form, I certify that the information contained herin is true, correct, and complete to the best of my knowledge and belief. I further acknowledge that any intentional false statement or misstatement may be a violation of 53a-180c.
     Please type your name below for the purpose of electronically signing this report (CT Sec. 1-272. Legal recognition of electronic records, electronic signatures and electronic contracts).
122. First and Last name*
123. Date Signed*
     Date Signed
Leave This Blank:


125. 1. Receive an email copy of this form.
126. Email address

     This field is not part of the form submission.

127. Submit

* indicates a required field