Fraud Complaint Form

Please fill out this form to send a complaint to the Department of Public Safety Alcohol and Gambling Enforcement Division.

Law enforcement or regulatory agencies may desire copies of pertinent documents regarding your complaint. Original documents should be retained for use by law enforcement agencies.

* = required field
Your Information
*Last Name:
Middle Name:
*First Name:
Business Name:
*Address:
*City:
*State: *Zip or Postal Code:
*Phone Number:   
E-mail Address:
Complaint Information
Business Name:
First Name:
Last Name:
Address:
City:
State or Province: Zip or Postal Code:
Country:
Phone Number:   
E-mail Address:
*Do you have pertinent
documents in paper form?		       Yes       No
*Did you lose money
to this scheme?		       Yes       No
If Yes, please indicate
the means of payment
(select all that apply)
Cash
Cashier's Check
Check/Debit Card
Credit Card
Money Order
Wire Transfer
Other Loss? (Specify)
Explain Your Problem:
Please limit to 2000 characters (approximately 30 lines)
How did the company or
individual initially contact you?
*Was the initial contact
unsolicited or uninvited?		       Yes       No
How much time has passed
since you became aware
it was a scam or fraud?
*Have you reported this crime?       Yes       No
If Yes, please indicate
who you contacted
(select all that apply)
Better Business Bureau
Consumer protection agency
Police or other law enforcement
Private attorney
Individual or business that victimized you



After information is entered, click Submit Form
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