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Requestor Contact Information:
Full Name*
Email*
Phone Number
Preferred Contact Method
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Email
Phone
complainant Information:
Full Name*
Address
City
Country
Zip/Postal Code
Phone Number
Email Address*
Financial Transaction(s):
Did you send or lose money?
Yes
No
Your total loss amount?
Contacted financial entity?
Yes
No
Transaction 1
Transaction Type
Select transaction type
Deposit / Receive
Withdrawal / Send
Swap / Trade
Buy
Sell
Transfer
Staking / Stake
Unstaking / Unstake
Airdrop
Reward / Mining Reward
Fee
Loan / Borrow
Repayment / Payback
NFT (Mint / Buy / Sell / Transfer)
Other
Transaction Amount
Transaction Date
Transaction ID/Hash*
Type of Cryptocurrency
-- Select Cryptocurrency --
Bitcoin (BTC)
Ethereum (ETH)
Tether (USDT)
USD Coin (USDC)
BNB (BNB)
Solana (SOL)
XRP (XRP)
Dogecoin (DOGE)
Cardano (ADA)
TRON (TRX)
Other
Originating Wallet Address
Recipient Wallet Address
Add Another Transaction
Remove Transaction
Supporting Information
Relevant URL/Social Media Account
Provide a description of the incident*
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