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Which cryptocurrency did you lose and how much?* Provide us with full information: e.g. 2.0 BTC, 100.15 XRP, 1000.75332 ETH

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Could you please provide us with the estimated value of your lost assets in USD ($)?* Please provide us with information related to lost amount as e.g. one thousand five hundred should be written as 1500 and one million should be written as 1000000

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When did you lose your cryptocurrency?* e.g. the exact day of the hack; the date of sending your assets to a scammer

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Where did you lose your cryptocurrency?* e.g. name of exchange, name of wallet, name of the website, name of scam etc.

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How did you lose your cryptocurrency?* e.g. blocked account on exchange, hacked wallet, fake giveaway etc.

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In which country were you in when you transferred your assets to a scammer/were you hacked/made a transaction in which a loss of cryptocurrency took place?

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Provide us with wallet addresses from which you lost funds.* e.g. your deposit wallet address from exchange/hacked wallet address/wallet address from which cryptocurrency was sent to scammer etc. Please do not provide us with a wallet address not associated with the case.

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Could you kindly confirm that you are the owner of the private keys for the addresses specified above? If so, please indicate the name of wallet application you were using (e.g. Electrum, Exodus, MyEtherWallet, MetaMask). Otherwise, if you are not the owner of the private keys for the addresses specified above, could you specify what exchange or custodial wallet was used by you in this case? (e.g. Binance, Freewallet, Xapo etc.)

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Provide us with the scammer’s/hacker’s wallet addresses. The address where your cryptocurrency has been sent

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Please provide us with transactions hashes connected to the case. * Each blockchain transaction has a unique hash dedicated only for the transaction e.g. hash used for Bitcoin is a 65-digit-hexadecimal number

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Could you please provide us with the deposit/withdrawal bank accounts used by the fraudulent platform/scam service? - if available. Please complete this field if you have deposited or withdrawn fiat from the fraudulent platform/scam service.

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Have you reported your case to the Law Enforcement (e.g. Police)? If you have reported your case to Law Enforcement, please let us know the name of the Law Enforcement you reported your case to, the date, and the feedback that you've gotten from them.

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Have you reported this case to any other organizations, beyond law enforcement? If you have reported your case to any other organization, please let us know the name of the organization, the date, and the feedback you have gotten from them.

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Email: *

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Firstname: *

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Surname:*

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Birth date*

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Country of residence:*

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Nationality:* If the Participant is a legal entity or other entity with the capability to undertake legal actions, the above sections (Name, Surname, Birth day, Phone number, Country of residence, Nationality) should be filled by a representative authorised to take part in Programme on its behalf.

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