I. Your information
First name:
Last name:
Phone number:
Where are you reporting from? *Street Address(line 1):
(line 2):
City:
State: - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
Country: - None -AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMonteneg**MontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe
Zip code:
II. Suspected Violation
Please check the violation that best applies *Location of Criminal Activity (if known)
(line 1):
(line 2):
City:
State: *- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip code:
III. Violator Information
The complaint involves a *Information about business/company
Information about business/company Business/Company Name: *
Business's Street Address(line 1):
(line 2):
City:
State: *- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip code:
Information about the individual
Information about the individual First name: *
Last name: *
Approximate age:
Individual's Street Address(line 1):
(line 2):
City:
State: *- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip code:
Have you previously submitted this information to any law enforcement or government agency? *If yes, provide the date, name of agency and other details in the narrative text box below. (limit 200 characters).
* Did you have additional businesses/individuals to report on? * PRIVACY ACT NOTICE/PAPERWORK REDUCTION ACT NOTICE
Authority: 6 U.S.C. § 203; 8 U.S.C. § 1103; 8 U.S.C. § 1357; 8 U.S.C. § 1360; 19 U.S.C. § 1589a; 5 U.S.C. § 552a; 5 U.S.C. § 301; and 44 U.S.C. § 3101 authorize ICE to collect your information requested in this web form. Please also see the privacy policy for ICE's public website available at ICE's Privacy Policy for additional information about the type of information that is collected about you when you visit this and other pages on the ICE.gov website.
Purpose(s): The information requested is being collected to initiate and/or support a law enforcement investigation. ICE may also use your information to contact you for additional details about your tip, or to arrange monetary payment, if applicable.
Routine Use(s): Your information and the information you provide in your tip regarding suspicious or suspected criminal activity and/or violation of law may be shared internally within to the Department of Homeland Security (DHS) for any appropriate law enforcement action. The information you provide may also be shared with other federal, state, local, tribal or foreign agencies in order to refer reports of suspicious activity, tips, potential violations of law and other relevant information to those agencies with appropriate jurisdiction, authorities, and/or need-to-know concerning the matter(s) you report. The information you provide may also be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, pursuant to the routine uses published in the Department of Homeland Security system of records notice, DHS/ICE-007 Alien Criminal Response Information Management.
Disclosure: In order to submit a tip using this web form, the disclosure of your contact information in this web form is voluntary. Should you wish to submit an anonymous tip via phone, you may call the HSI Tip Line at (866) 347-2423.
Public Reporting Burden: U.S. Immigration and Customs Enforcement is collecting this information as a part of its agency mission under the Department of Homeland Security. The estimated average time to review the instructions, search existing data sources, gather and maintain the data needed and completing and reviewing this collection of information is 10 minutes (0.166 hours) per response. An agency may not conduct or sponsor, and a person is not required to respond to, an information collection unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Office of the Chief Information Officer, Forms Management Office, 801 I Street NW, Washington, DC 20536-5800, ATTN: PRA Officer. Do not return the completed form to this address.
WARNING REGARDING KNOWINGLY PROVIDING FALSE INFORMATION
The information I've provided on this form is correct to the best of my knowledge. I understand that providing false information could subject me to fine, imprisonment, or both. (Title 18, U.S.C. § 1001).
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