Report of Child Exploitation
NOTE: Fields marked * are required. w
1. INCIDENT SUMMARY
Type of Incident *
Date of Incident (mm/dd/yyyy) *
Time of Incident (hour:min:sec) *
Time Zone *
Location of Incident (city and state where incident occurred)
2. REPORTING PERSON
Name *
Street Address
City
State
Zip
Country
Email address *
Phone
Additional Phone
Relationship to Child
3. INTERNET INFORMATION
If applicable, please fill out the following information:

Date Accessed (mm/dd/yyyy)
Time Accessed (hour:min:sec)
Internet Location (e.g. Newsgroups, FTP, etc.)
Website/HTTP/URL/FTP
Chatroom: Name or Location if not IRC
IRC Channel Name
IRC Server Name
HTTP/FTP Login
HTTP/FTP Password
Email/Newsgroup Header
4. CHILD VICTIM
If applicable, please fill out the following information:

Name
Street Address
City
State
ZIP
Country
Email Address
Date of Birth (mm/dd/yyyy)
Approximate Age
5. SUSPECT
If applicable, please fill out the following information:

Name
Street Address
City
State
ZIP
Country
Approximate Age
Email Address
Screen/Username
ICQ#
IP Address
6. LAW ENFORCEMENT INFORMATION
If applicable, please fill out the following information:

Agency Name
Officer's Name
Officer's Phone
7. ADDITIONAL INFORMATION
Please provide additional information or description (be specific). If reporting websites, please limit to 5 in each report. Other victims or suspects should be listed in this section.

Additional Information
CAPTCHA security code
Please enter the characters above:

*

PLEASE VERIFY YOUR REQUEST ABOVE BEFORE SUBMITTING: