Complaint Form : CYBER CRIME POLICE STATION, KARNATAKA (Financial Frauds)

CCP/BLR NO:
¸ÀAvÀ¸ ÀÛ À ªÀiÁ»w/VICTIM INFO
æ g

ºÉ¸ÀgÀÄ/Name

vÀAzÉAiÀÄ ºÉ¸ÀgÀÄ/Father's Name

ªÀÈwÛ/Profession

ªÀAiÀĸÀÄ/ì Age °AUÀ/Gender

«¼Á¸À/Address

£ÀUÀgÀ/HgÀÄ City/ Village f¯É/è District

CAZÉ/PIN Code

zÀÆgÀªÁtÂ/Phone

E-ªÉÄïï/Email Address

ªÀåªÀºÁjPÀ ªÀ»ªÁlÄ/FINANCIAL TRANSACTION (s)

Mn¦, PÁqïð, D£ï¯ÉÊ£ï ªÀ»ªÁlÄ, ªÉƨÉʯï D¥ïì.... /OTP,

Card, Online Transfer, Cash, Digital Wallets, Phone apps
etc.

ªÀ»ªÁlÄ jÃw/Transaction Type

ªÀ»ªÁlÄ ªÉÆvÀÛ/Transaction Amount

ªÀ»ªÁlÄ ¢£ÁAPÀ (EAzÀ-UÉ)/

Transaction Dates (From - To)

Û À CPËAmï ¸ÀASÉå/Victim Account Number

¸ÀAvÀæ¸Àg

Û À ¨ÁåAPï ºÉ¸ÀgÀÄ/Victim Bank Name

¸ÀAvÀæ¸Àg

Û À ¨ÁåAPï ¨ÁæAZïÀ «¼Á¸À/Victim Bank Branch

¸ÀAvÀæ¸Àg
Address

SÁvÉAiÀÄ ºÉ¸ÀgÀÄ/ Account

¥sÀ¯Á£ÀĨsÀ«AiÀÄ ¨ÁåAPï «ªÀgÀ/Beneficiary Bank Details ¨ÁåAPï ºÉ¸ÀgÀÄ/Bank Name SÁvÉAiÀÄ ¸ÀASÉå/Account Number
Name
ªÀ»ªÁlÄ #1/Transaction #1
ªÀ»ªÁlÄ #2/Transaction #2
ªÀ»ªÁlÄ #3/Transaction #3
ªÀ»ªÁlÄ #4/Transaction #4
ªÀ»ªÁlÄ #5/Transaction #5
ªÀ»ªÁlÄ #6/Transaction #6
ªÀ»ªÁlÄ #7/Transaction #7

ªÉƸÀªÀiÁrzÀªÀgÀ ªÀiÁ»w (¤ªÀÄä w¼ÀĪÀ½PÉAiÀÄAvÉ)/Information About The Suspect(s) ( As per your knowledge)

ºÉ¸ÀgÀÄ/Name

ªÀÈwÛ/Profession

zÀÆgÀªÁtÂ/Phone number

E-ªÉÄïï/Email Id

ªÉ¨ï¸ÉÊmï AiÀÄÄDgïJ¯ï/Website URL

(e.g.www.example.com)

EvÀgÉ AiÀiÁªÀÅzÁzÀgÀÄ ªÀiÁ»w?/ Any other

information?

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WÀl£ÉAiÀÄ «ªÀgÀ/DESCRIPTION OF INCIDENT (MODUS OPERANDI)

AiÀiÁªÀ jÃw ªÉÆøÀºÉÆÃzÀgÉA§ WÀl£ÉAiÀÄ (¸ÀAQë¥Û)À «ªÀgÀ

/ Provide a description of the incident and how you were victimized (Facts in brief)

PɼV
À gÀĪÀ AiÀiÁªÀÅzÀÄ zÀÆjUÉ ¸ÀA§AzsÀ¥ÀnÖzÉ (¸ÀA§AzsÀ ¥ÀlÖPÌÉ nPï ºÁQ)
/ Which of the following were used in this incident? Modus Operandi (Check ✓ all that Apply)
OTP PÉüÀ®Ä ¥sÆ
É Ã£ï PÀgÉ/ Phone call
to ask OTP /SMS
¸ÀéAiÀÄA ªÀUÁðªÀuÉ/ Self Transfer
CzÉà vÀgÀºÀzÀ £ÀPÀ° ªÉ¨É¸ÉÊmï/ Similar
fake bank website
¨ÁåAPï SÁvÉ ºÁåPï/ Bank Account hacked

E-ªÉÄïï SÁvÉ ºÁåPï/ Email Hacked

JnJªÀiï ¹Ì«ÄäAUï / ATM Skimming

EvÀgÉ (zÀAiÀÄ«lÄÖ £ÀªÀÄÆ¢¹)
/Others (Please specify)

Û (¹¹n« vÀÄtÄPÀÄ, ¥sÉÆÃmÉÆUÀ¼ÀÄ, J¸ïJAJ¸ï, «rAiÉÆÃ, EvÀgÉ..) / Please attach all copies of pertinent documents or
zÀÆjUÉ ¸ÀA§AzsÀ¥ÀlÖ, J¯Á è zÁR¯ÉUÀ¼ÀÄ/¸ÁQëUÀ¼À ¥ÀæwAiÀÄ£ÀÄß ®UÎÀw¹
other evidence regarding your complaint. e.g. email, Bank statement, CCTV footage, SMS, Photos, Videos, documents?

Û gÀĪÀ zÁR¯ÉUÀ¼À «ªÀgÀ/List of evidences

®UÀÎw¹
submitted

ºÉZÀÄѪÀj «ªÀgÀ/ADDITIONAL INFORMATION

ÀÛ ÀÄ EzÁÝgÉAiÉÄ?/Are there any other witnesses or victims to this incident?

F WÀl£ÉUÉ ¸ÀA§A¢ü¹zÀAvÉ,É EvÀgÉ ¸ÁQëUÀ¼ÀÄ/¸ÀAvÀæ¸g

WÀl£ÉAiÀÄ §UÎÉ EvÀgÉ AiÀiÁªÀÅzÁzÀgÀÄ PÁ£ÀÆ£ÀÄ eÁj KeɤìUÉ ªÀgÀ¢ ¤ÃrzÀ°è, KeɤìAiÀÄ ºÉ¸ÀgÀÄ, zÀÆgÀªÁtÂ, ªÀgÀ¢AiÀÄ ¢£ÁAPÀUÀ¼À£ÀÄß ¤Ãr/If you have reported this incident to other law
enforcement agencies, please provide the name, phone number, email, date reported, report number.

F »AzÉ ¸À°¹ègÀĪÀ zÀÆjUÉ, ºÉaÑ£À ªÀiÁ»w ¸À°è¸ÄÀ wÛzÝÀ °,è nPï

ªÀiÁr / Check here if this an update to a ºËzÀÄ/ YES E®è / NO
previously filed complaint:

À zÁgÀ/UNDERSIGNED
PɼÀ¸»

ªÉÄÃ¯É MzÀV¹gÀĪÀ ªÀiÁ»wAiÀÄÄ £À£Àß w¼ÀĪÀ½PÉAiÀÄ ªÉÄÃgÉUÉ ¤RgÀ ºÁUÀÆ ¸ÀvåÀ ªÁVgÀÄvÉA
Û zÀÄ ¥ÀæªÀiÁt¸ÀÄvÉÃÛ £É. vÀ¦à£ÁA±À EzÀÝ° z À qÀ/eÉʮĪÁ¸À CxÀªÁ JgÀqÀPÀÆÌ §zsÞÀ £ÁVgÀÄvÉÃÛ £/I affirm that the
è A
information I provided is true and accurate to the best of my knowledge.I understand that providing false information could make me subject
to fine, imprisonment, or both.

¸À»/Signature

ºÉ¸gÀÄÀ /Name

¸Àܼ/À Place ¢£ÁAPÀ/Date

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