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	Do you have a fraud or financial exploitation concern? Complete this complaint form or call us Monday - Friday 9am to 4 pm Toll Free in Colorado: 1-800-222-4444 Denver Metro: 303-222-4444 If using this form, please note that labels in bold with an asterisk (*) are required


	Your Information

	* First Name:
	* Last Name:
	Phone Number:	(nnn-nnn-nnnn)
	Email:
	Would you like to receive a status update?	Yes No
	* Relationship to Victim:
	* Type of Complaint:
	* Estimated Amount of Financial Loss:	(to the nearest $)
	* Are you the Contact?	Yes No
	Will you share your fraud experience with the public in order to help others? Yes No
	How did you hear about us?


	Contact Information


	Victim Information

	* First Name:
	Middle Initial:
	* Last Name:
	* Street Address 1:
	Street Address 2:
	* City, State:	,
	* Zip:	(nnnnn or nnnnn-nnnn)
	* County:
	Is the Mailing Address the same as the Street Address? Yes No
	* Mailing Address 1:
	Mailing Address 2:
	* City, State:	,
	* Zip:	(nnnnn or nnnnn-nnnn)
	* County:
	Phone Number 1:	(nnn-nnn-nnnn)
	Phone Number 2:	(nnn-nnn-nnnn)
	Email:
	* Age:
	* Marital Status:
	Ethnicity:
	* Gender:
	Primary Language:
	Number of people in household:	(1 to 99)
	Is the victim the person making the financial decision? Yes No
	If not, then who?
	Victim Partner First Name:
	Victim Partner Last Name:


	Perpetrator Information

	Company Name:
	First Name:
	Last Name:
	Street Address 1:
	Street Address 2:
	City, State:	,
	Zip:	(nnnnn or nnnnn-nnnn)
	County:
	Is the Mailing Address the same as the Street Address? Yes No
	Mailing Address 1:
	Mailing Address 2:
	City, State:	,
	Zip:	(nnnnn or nnnnn-nnnn)
	County:
	Phone Number 1:	(nnn-nnn-nnnn)
	Phone Number 2:	(nnn-nnn-nnnn)
	Relationship to Victim:
	How was the victim contacted by the perpetrator?
	Additional perpetrator information:


	Summary Information

	* Report Summary:
	Date of Occurrence:	(mm/dd/yyyy)