TI SURVEY &

ACCOUNT OF HARASSMENT

Please fill out this survey for demographic and legal purposes.  You may copy and paste it into a word processor program or print out the pdf file, located here:

www.freedomfchs.com/tisurveyforprintout.pdf

NAME:

ADDRESS:

CITY AND STATE:

ZIP CODE:

DATE:

PHONE:

EMAIL:

BLOG:

WEBSITE:

DATE OF BIRTH:

GENDER : ___ MALE ___ FEMALE

WHERE TARGETING STARTED:

WHEN TARGETING STARTED:

WHO DO YOU BELIEVE IS TARGETING YOU, IF KNOWN?

ARE YOU AN ELECTROMAGNETIC HARASSMENT VICTIM? ___Yes ___No

DO YOU FEEL YOU HAVE IMPLANTS? ___ Yes ___ No ___ Not Sure

HAVE YOU REPORTED YOUR HARASSMENT TO YOUR LOCAL POLICE? ___ Yes ___ No

IF YES, WHAT WAS THEIR RESPONSE?

HAVE YOU REPORTED YOUR HARASSMENT TO THE FBI? ___ Yes ___ No

IF YES, WHAT WAS THEIR RESPONSE?

HAVE YOU SOUGHT ASSISTANCE REGARDING YOUR HARASSMENT FROM YOUR STATE OR CONGRESSIONAL OFFICIALS? ___ Yes ___ No

IF YES, WHAT WAS THEIR RESPONSE?

DO YOU LIVE NEAR A:

Military Base: Name and City

Defense Contractor: Name and City

Weapons Manufacturer: Name and City

Government Intelligence Agency: Name and City

Major University: Name and City

Major Hospital: Name and City

Biomedical Research Facility: Name and City

Psychiatric Facility: Name and City

SYMPTOMS: Have you or are you experiencing the following: Check all that apply

Organized Stalking:

___ Appliance Tampering                       ___ Helicopter/Airplane home

___ Being Followed                                      flyovers

___ Blacklisting                                      ___ Home Entry

___ Car Tampering                                ___ Home Monitoring

___ Community-based Harassment          ___ Job Harassment

       Activity                                           ___ Mail Tampering

___ Computer Tampering                       ___ Noise Campaigns

___ E-mail Monitoring/Interference          ___ Street Theater

___ Emergency Vehicle Harassment         ___ Targeting of Pets

      (police, fire trucks, ambulances)        ___ Unexplained sounds in home

___ Estrangement of family, friends         ___ Wiretapping

___ Food Tampering

Electromagnetic Harassment:

If applicable, please cite one or more examples of each of the following:

(Attach additional sheet, if necessary)

Assault/Battery

In most states, an assault/battery is committed when one person 1) tries to or does physically strike another, or 2) acts in a threatening manner to put another in fear of immediate harm. Many states declare that a more serious or "aggravated" assault/battery occurs when one 1) tries to or does cause severe injury to another, or 2) causes injury through use of a deadly weapon. Historically, laws treated the threat of physical injury as "assault," and the completed act of physical contact or offensive touching as "battery," but many states no longer differentiate between the two.

Burglary

Burglary is typically defined as the unlawful entry into almost any structure (not just a home or business) with the intent to commit any crime inside (not just theft/larceny). No physical breaking and entering is required; the offender may simply trespass through an open door. Unlike robbery, which involves use of force or fear to obtain another person's property, there is usually no victim present during a burglary.

For example, Dan enters Victor's boathouse through an open window, intending to steal Victor's boat. Finding the boat is gone, Dan returns home. Though he took nothing, Dan has committed burglary.

Computer crime laws in many states prohibit a person from performing certain acts without authorization, including 1) accessing a computer, system, or network; 2) modifying, damaging, using, disclosing, copying, or taking programs or data; 3) introducing a virus or other contaminant into a computer system; 4) using a computer in a scheme to defraud; 5) interfering with someone else’s computer access or use; 6) using encryption in aid of a crime; 7) falsifying e-mail source information; and 8) stealing an information service from a provider.

Conspiracy

A criminal conspiracy exists when two or more people agree to commit almost any unlawful act, then take some action toward its completion. The action taken need not itself be a crime, but it must indicate that those involved in the conspiracy knew of the plan and intended to break the law. One person may be charged with and convicted of both conspiracy and the underlying crime based on the same circumstances.

For example, Andy, Dan, and Alice plan a bank robbery. They 1) visit the bank first to assess security, 2) pool their money and buy a gun together, and 3) write a demand letter. All three can be charged with conspiracy to commit robbery, regardless of whether the robbery itself is actually attempted or completed.

Hate Crime

Hate crime is the violence of intolerance and bigotry, intended to hurt and intimidate someone because of their race, ethnicity, national origin, religious, sexual orientation, or disability. The purveyors of hate use explosives, arson, weapons, vandalism, physical violence, and verbal threats of violence to instill fear in their victims, leaving them vulnerable to more attacks and feeling alienated, helpless, suspicious and fearful.

Murder: First Degree

In most states, first-degree murder is defined as an unlawful killing that is both willful and premeditated, meaning that it was committed after planning or "lying in wait" for the victim.

Stalking & Harassment

Stalking laws in most states pertain to a relatively new crime involving a clear pattern of conduct in which the offender follows, harasses, or threatens another person, putting that person in fear for his or her safety. An individual may be charged with stalking regardless of any pre-existing relationship with the victim. Stalking victims can range from celebrities to former spouses who have obtained a protective order against their ex.

For example, Dan spends a number of hours each week harassing Victoria, his former girlfriend, by following her home from work, sending her threatening emails, and calling her in the middle of the night.

Wire Fraud

Wire fraud crimes refer broadly to any fraudulent or deceitful scheme to secure money or property, committed or aided through the use of interstate "wires" -- meaning television, radio, telephone, or computer modem. Almost all instances of wire fraud are considered federal crimes, due to their potential interstate effects.

YOUR ACCOUNT OF WHAT IS HAPPENING TO YOU, INCLUDING WHO YOU BELIEVE IS TARGETING YOU AND WHY:

(Attach separate sheet, if necessary)

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