Form 73-XXX Allegation of Counterfeiting and Piracy

DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement
National Intellectual Property Rights Coordination Center

ALLEGATION OF COUNTERFEITING
AND INTELLECTUAL PIRACY
The National Intellectual Property Rights Coordination Center (IPR Center) is the U.S. government's clearinghouse for investigations
into counterfeiting and piracy — crimes that threaten the public's health and safety, the U.S. economy, and our war fighters.
The IPR Center encourages members of the general public, industry, trade associations, law enforcement and government agencies to
report potential violations of intellectual property rights through this website. The information you provide will be reviewed promptly by
IPR Center staff and disseminated for appropriate investigative response and tactical use to IPR Center partners.
Completion of this referral form is voluntary. The IPR Center accepts online complaints from actual victims as well as from third parties
to the victims. While providing your contact information is voluntary, the IPR Center can best process a complaint if it receives accurate
information in the form and has the ability to contact the complainant to clarify information that was provided, when necessary. There
are various resources, such as the IPR Center’s pamphlet Reporting Allegations of Intellectual Property Theft and the Department
of Justice, Computer Crime and Intellectual Property Section’s publication Reporting Intellectual Property Crime: A Guide for
Victims of Counterfeiting, Copyright Infringement, and Theft of Trade Secrets that may aid in reporting violations of intellectual
property rights and assist you in completing this form. Please provide as much of the following information as possible to assist us in
investigating the report.
Information about the Individual/Business that violated intellectual property rights:
Business Name:
First Name:

Middle Initial:

Last Name:

Gender:

Address (Include Suite/Apt./Mail Stop):
City:

State:

Phone Number:

Country:

Zip Code / Route:

Email Address:

Other Identifiers about the Individual/Business that violated intellectual property rights:
Web Site:
IP Address:
Social Media site:

Social Media user account:

Monetary Loss:
Please estimate the total dollar amount of your loss from this incident:
$
(US Dollars) Enter 0 for no loss

Did you use a third party online payment service?
Yes
No

What type of third party online payment service did you use?
Please indicate the means of payment (select all that apply):
Cash
Cashier's Check
Check/Debit Card
Wire Transfer

Credit Card

Gift Card

Money Order

Other (Specify Other):

Type of Commodity:
Does your complaint involve a government contract?
Yes
No
What type of commodity was involved? (Check applicable commodities)
Automotive Parts/Accessories

Electronics: Computer Hardware

Wearing Apparel/Accessories: Jerseys

CDs Piracy: Music

Electronics: Computer Software

Wearing Apparel/Accessories: Jewelry

Cigarettes

Food Substances

Wearing Apparel/Accessories: Shoes

Cyber Financial Fraud

Hygiene/Cosmetics

Other/Miscellaneous (Specify):

DVDs Piracy: Movie

Pharmaceuticals

DVDs Piracy: TV

Trade Secrets Theft

Electronics: Computer Accessories

Wearing Apparel/Accessories: Handbags

ICE Form XXX_WIZ (8/14)

Submission ID:

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Description of the Incident:
Describe in your own words how you have been victimized or how intellectual property rights were violated. (Be specific. Include
date(s) of transaction(s), a description of any items that were not delivered or were counterfeited, any transaction numbers, and any
other pertinent information that helps to explain the violation. Also if you received anything by U.S. Mail or any other delivery service,
specifically describe the envelope, by the date, time, city and zip code shown on the stamp cancellation postmark).

Additional Information:
If applicable, please indicate the initial means of contact with the individual/business that violated intellectual property rights:
If applicable, was this initial means of contact unsolicited/uninvited?
No
Yes
What was your relationship with the individual/business you are complaining about prior to the incident you are reporting?
Did you conduct any research on the individual/business prior to the incident?
Yes
No
How much time has passed since you determined that the individual/business was violating intellectual property rights?
Are there witnesses or other victims to this crime? If yes, please provide names, addresses, phone numbers, email addresses, and/
or websites of where they can be found (optional).
Witness or Victim 1:
First Name:
Middle Initial: Last Name:
Address (Include Suite/Apt./Mail Stop):
City:
Phone Number:
ICE Form XXX_WIZ (8/14)

State:
Email Address:

Country:

Zip Code / Route:
Web Site:
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Witness or Victim 2:
First Name:

Middle Initial:

Last Name:

Address (Include Suite/Apt./Mail Stop):
City:
Phone Number:

State:

Country:

Zip Code / Route:

Email Address:

Web Site:

Additional Witness/Victim Information:

Have you already reported this crime to any law enforcement or government agencies? If yes, please indicate the organizations/
individuals that you contacted (select all that apply).
Better Business Bureau
Police/other law enforcement
Consumer protection agency

Private attorney

Individual/business that victimized you

Other (Specify Other)

Provide the specific name of each organization, contact name, contact phone number, email address, date reported, and report
number (if known).
Organization 1:
Organization Name:
Contact Name:
Phone Number:

Email Address:

Organization 2:
Organization Name:
Phone Number:

Date Reported:

Report Number:

Contact Name:
Email Address:

Date Reported:

Report Number:

Do you have pertinent documents/correspondence in paper or electronic form?
Yes
No
*Original documents should be retained for use by law enforcement agencies*
Additional Organization Information:

Contact Information:
Your report will remain anonymous unless you choose to identify yourself; however, please note that failure to do so may limit or
otherwise compromise the IPR Center and its partners’ efforts to conduct an investigation based on your information. If you agree to
be contacted with follow-up questions, if necessary, please enter your contact information:
First Name:
Middle Initial: Last Name:
Business Name:

ICE Form XXX_WIZ (8/14)

Phone Number:

Email Address:

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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 knowingly and willfully
providing false information could subject me to fine, imprisonment, or both. (Title 18, U.S.C. § 1001).
Privacy Act Statement - IPR Center Reporting Allegations of Counterfeiting and Intellectual Piracy Form
Authority: 5 U.S.C. § 301; 5 U.S.C. § 552a; 6 U.S.C. § 203; 8 U.S.C. § 1103; 19 U.S.C. § 1589a; 44 U.S.C. § 3101 authorize U.S.
Immigration and Customs Enforcement (ICE) to collect your information requested in this web form.
Purpose(s): The information being requested is collected and controlled by the ICE-led National Intellectual Property Rights
Coordination Center (IPR Center) for the purpose of evaluating and further developing information in support of law enforcement
investigations. The IPR Center may also use your information to contact you for additional and/or clarifying information about your
report.
Routine Use(s): Your information and the information you provide regarding suspicious or suspected criminal activity and/or
violation of law may be shared internally within 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, territorial, 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, and pursuant to the routine
uses published in the DHS system of records notice, DHS/ICE-009 External Investigations.
Disclosure: Use of this form and the disclosure of your contact information when submitting this form are voluntary. Should you
wish to submit an anonymous report verbally, you may call the IPR Center Hotline at 1-866-IPR-2060 or 1-866-477-2060.
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 30 minutes (.5 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 U.S. Immigration and customs Enforcement, Forms Management Office,
801 I Street NW, Washington D.C. 20536-5800. Do not mail your completed form to this address.

ICE Form XXX_WIZ (8/14)

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For Industry Use

Entities (Persons or Businesses) engaged in production, transportation, distribution or sale of counterfeit goods, foreign or domestic
(Manufacturers, Shippers, Trading Companies, Freight Forwarders, Importers, Brokers, Individuals, etc.), or information regarding
specific shipments.
Entity Name
Entity Address
Entity Phone Number
Entity URL (web address)
Entity IP (internet protocol)
Foreign Places of Receipt
Foreign Ports of Lading
Domestic Ports of Arrival or Entry
Cargo Descriptions Used
Container Number (s)
Entities subject to Cease & Desist letters, Suits, Arrests, Prosecutions, etc., foreign or domestic.
Entity Name
Entity Address
Entity Phone Number
Entity URL (web address)
Entity IP (internet protocol)
Seizures executed overseas by foreign Customs or Law Enforcement and the shipping or manifest information associated with those
seizures.
Country
Port
Importer Name
Importer Phone Number
Importer Address
Exporter Name
Exporter Phone Number
Exporter Address
Freight Forwarder Name
Freight Forwarder Address
Freight Forwarder Phone Number
Counterfeit Goods Seized
Cargo Description(s) Used
Weight
Quantity
Destination Port (if different than
detection Port)
Container Number(s)

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