Victim Fund Nomination Form

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Your Name

First

Last

Email

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Who are you nominating as a victim fund recepient?

First

Last

Layout

Nominee’s Email

Nominee’s Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please provide pertinent information relative to nominee being victimized as a result of scam or fraud. Important information to include is date, location, specifics of scam, etc.

Was scam/fraud reported to law enforcement. If so, please provide agency name, date reported, report number, etc.

How do you know the nominee?

Please provide any Website URL links which provide any additional information relative to specifics of the scam. This may include newspress coverage, TV New coverage, YouTube channel coverage, etc.

Please upload any copies of law enforcement reports, incident reports, press clipping, etc.

Click or drag a file to this area to upload.