CRYPTOCURRENCY SCAM INTAKE QUESTIONNAIRE Enter your email address to receive a copy of this form(Required) 1. VICTIM InfoName DOB Address (residence) Address (work) Occupation Current phone number DL/ID Number Current email address 2. When did this incident begin, and when was the last activity?3. What is the amount of actual financial loss you suffered, if any?4. What cryptocurrency wallet address(es) or exchange accounts did the losses originate from?5. If cryptocurrency was sent to you from your wallet or account, what address(es) was it sent to?6. Please identify in as much detail as possible the cryptocurrency transactions involved, including sending and receiving addresses, transaction IDs, date/time, and amounts. (Make as many copies of this table as you need.)Transaction 1Cryptocurrency type Transaction ID From what wallet / address / exchange To address(es) Date/Time Amount Sent Other information Transaction 2Cryptocurrency type Transaction ID From what wallet / address / exchange To address(es) Date/Time Amount Sent Other information Transaction 3Cryptocurrency type Transaction ID From what wallet / address / exchange To address(es) Date/Time Amount Sent Other information Transaction 4Cryptocurrency type Transaction ID From what wallet / address / exchange To address(es) Date/Time Amount Sent Other information Transaction 5Cryptocurrency type Transaction ID From what wallet / address / exchange To address(es) Date/Time Amount Sent Other information Transaction 6Cryptocurrency type Transaction ID From what wallet / address / exchange To address(es) Date/Time Amount Sent Other information 7. Describe what happened including how you first came into contact with the suspect, what means of communication you used, what accounts were used, what claims were made, and what actions resulted in financial loss.8. Please identify, as specifically as possible, any web sites or applications used in this scheme.9. When was your last contact with the suspect or anyone connected to the suspect, and what was that interaction?10. Please identify any accounts involved in this incident, such as those used to communicate with a suspect and those used to send or receive any financial assets. (Make as many copies of this table as you need.) Account 1Type of account Platform Account identifier (username) Account identifier (number or other ID) How was this account involved Who created and/or used the account Did the suspect have access to this account at any time Please provide any supporting documentation available such as screen shots, downloads, emails received from service providers, etc. Drop files here or Select files Max. file size: 40 MB. Account 2Type of account / Platform Account identifier (username) Account identifier (number or other ID) How was this account involved? Who created and/or used the account? Did the suspect have access to this account at any time? Please provide any supporting documentation available such as screen shots, downloads, emails received from service providers, etc. Drop files here or Select files Max. file size: 40 MB. Account 3Type of account / Platform Account identifier (username) Account identifier (number or other ID) How was this account involved? Who created and/or used the account? Did the suspect have access to this account at any time? Please provide any supporting documentation available such as screen shots, downloads, emails received from service providers, etc. Drop files here or Select files Max. file size: 40 MB. Account 4Type of account / Platform Account identifier (username) Account identifier (number or other ID) How was this account involved? Who created and/or used the account? Did the suspect have access to this account at any time? Please provide any supporting documentation available such as screen shots, downloads, emails received from service providers, etc. Drop files here or Select files Max. file size: 40 MB. 11. If you have reported this incident to any other law enforcement agency, including iC3, please list that information below. (Make as many copies of this table as you need.)Agency/Department Reference or case number Contact person if applicable Status Agency/Department Reference or case number Contact person if applicable Status 12. Describe any attempts you have made to trace and/or recover your cryptocurrency, including any contact you have made with exchanges.13. Please include any other information you believe will assist in the investigation. Supporting documents, files, screen shots may be included but are not a substitute for completing the items requested in this form. Drop files here or Select files Max. file size: 40 MB. Examples: