Source: https://complaint.ic3.gov/
Timestamp: 2019-04-26 10:30:12+00:00

Document:
Please complete one section for each financial transaction or attempted transaction related to this complaint. If there are no financial details, please proceed to the next section.
Description of Incident * Provide a description of the incident and how you were victimized. Provide information not captured elsewhere in this complaint form.
Law enforcement or regulatory agencies may desire copies of pertinent documents or other evidence regarding your complaint.
Originals should be retained for use by law enforcement agencies.
Please complete one section for each subject who victimized you. If subject(s) are not known, proceed to the next section.
Other Information If an email was used in this incident, please provide a copy of the entire email including full email headers.
Are there any other witnesses or victims to this incident?
If you have reported this incident to other law enforcement or government agencies, please provide the name, phone number, email, date reported, report number, etc.
The collection of information on this form is authorized by one or more of the following statutes: 18 U.S.C. § 1028 (false documents and identity theft); 1028A (aggravated identity theft); 18 U.S.C. § 1029 (credit card fraud); 18 U.S.C. § 1030 (computer fraud); 18 U.S.C. § 1343 (wire fraud); 18 U.S.C 2318B (counterfeit and illicit labels); 18 U.S.C. § 2319 (violation of intellectual property rights); 28 U.S.C. § 533 (FBI authorized to investigate violations of federal law for which it has primary investigative jurisdiction); and 28 U.S.C. § 534 (FBI authorized to collect and maintain identification, criminal information, crime, and other records).
The collection of this information is relevant and necessary to document and investigate complaints of Internet-related crime. Submission of the information requested is voluntary; however, your failure to supply requested information may impede or preclude the investigation of your complaint by law enforcement agencies.
The information collected is maintained in one or more of the following Privacy Act Systems of Records: the FBI Central Records System, Justice/FBI-002, notice of which was published in the Federal Register at 63 Fed. Reg. 8671 (Feb. 20, 1998); the FBI Data Warehouse System, DOJ/FBI-022, notice of which was published in the Federal Register at 77 Fed. Reg. 40631 (July 10, 2012). Descriptions of these systems may also be found at www.justice.gov/opcl/doj-systems-records#FBI. The information collected may be disclosed in accordance with the routine uses referenced in those notices or as otherwise permitted by law. In accordance with those routine uses, the FBI may disclose information from my complaint to appropriate federal, state, local, tribal or international law enforcement and regulatory agencies.

References: § 1028
 § 1029
 § 1030
 § 1343
 § 2319
 § 533
 § 534