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Information entered into this form will be forwarded to law enforcement for investigation and review.
To Submit Information on Missing Children Call 1-800-THE-LOST.

Reporting Person    (Help)
Top of Page

Approximate Date and Time of Incident - REQUIRED
Month
MM		 Day
DD		 Year
YYYY		 Hour Min Time Zone
:
Type of Incident - REQUIRED

Location of Incident (City & State where incident occurred)
First Name
Last Name
Address
 City
State *If USA
 Postal Code
 Country
State *If Not USA E-mail Address
Phone # (xxx-xxx-xxxx)
 Additional Phone #
Time Available for Callback
Relationship to Child

If applicable, please fill in the information below:
Internet Information    (Help) Top of Page

Date and Time Accessed
Month
MM		 Day
DD		 Year
YYYY		 Hour Min
: Reporting spam?    

Internet Location (e.g. Newsgroups, FTP, etc.)
Website/HTTP/URL/FTP
Chatroom: Name or Location if not IRC
IRC Channel Name
 IRC Server Name
FServe Trigger
HTTP/FTP Login
 HTTP/FTP Password
E-mail/Newsgroup Header
Logs of Conversation?

If applicable, please fill in the information below:
Child Victim    (Help) Top of Page

First Name
 Last Name
Address
 City
State *If USA
 Postal Code
 Country
State *If Not USA E-mail Address
Date of Birth (mm/dd/yyyy)
 Approximate Age
 * Other Children?

If applicable, please fill in the following information:
Suspect    (Help) Top of Page

First Name
 Last Name
Address
 City
State *If USA
 Postal Code
 Country
State *If Not USA
 Approximate Age
E-mail Address
Screen/User Name
 ICQ #
 IP Address
* Other Suspects?

Law Enforcement Information    (Help) Top of Page

Incident Has Been Reported to Law Enforcement
Agency Name
Officer's First Name
 Officer's Last Name
Officer's Phone # (xxx-xxx-xxxx)

Additional Information    (Help) Top of Page

Please provide additional information or description (be specific). If reporting multiple websites, please limit to 5 in each report.
*Other victims or suspects should be listed in this section



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