◆ SpookStack

Information about the Individual/Business that victimized you. Business Name: b6 b7C Name: Gender: Address: City: State: Country: Zip Code/Route: Phone number: Email Address: Other Identifiers Web Site: 1P Address: IRC Server: Chat Room Name: Usenet Newsgroup: Other: Monetary Loss If you lost money from the incident you are reporting, please specify the total dollar amount of your loss b6 b7C Please indicate the means of payment (select all that apply). Cash Cashier's Check Check/Debit Card ICredit Card Money Order Wire Transfer Other (Specify)Western Union Did you use a third party online payment service such as PayPal, BidPay, Escrow? Yes. Page 2 of 5