Payment Card Skimming Incident Report Form
Report a suspected or confirmed payment card skimming incident. Please provide detailed and accurate information to assist with the investigation.
Incident Type
*
Suspected Skimming
Confirmed Skimming
Date and Time of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (Business Name and Address)
*
The Last 4 Digits of Your Credit Card
*
Your Name
*
First Name
Last Name
Your Contact Email
*
example@example.com
Describe the Incident (What happened? How did you discover it?)
*
Upload Any Evidence (e.g., photos of device, receipts, etc.)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Have you reported this to law enforcement or the business?
Yes, to law enforcement
Yes, to the business
No
Preferred Follow-Up Method
Email
Phone (please specify below)
No follow-up needed
Submit Report
Should be Empty: