Fraud/Scam Investigation RequestPlease enable JavaScript in your browser to complete this form.Personal Information - Step 1 of 4Legal Name & Current AddressPlease enter your legal name as it appears on your primary identification document along with your current mailing address, your contact information, and your DOB and SSN. Entering as much information as possible will better assist law enforcement in an investigation. Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth (DOB) *Social Security Number (SSN)E-Mail Address *EmailConfirm EmailMobile Phone *NextHave you ever been a victim of any theft, scams, or fraud in the past? *YesNoHave you done business with this person(s) in the past? *YesNoAre you still communicating with this person(s)? *YesNoHow were you originally contacted by this person(s)? *PhoneEmailText MessageOtherSpecific to this loss, how many transactions were involved? *A single transactionMore than one transaction in a single dayMultiple transactions over multiple daysDid you report this to the police or any other law enforcement? *YesNoPlease provide the police department, name of a detective, case number, and phone number:PreviousNextWhat is the total amount of funds you sent (USD)? *Which CoinMover kiosk location(s) did you use? *How did you find the CoinMover kiosk? *Who did you think you were sending the funds to? *Describe what happened in detail below:Do you have contact information from the person(s) who contacted you? *YesNoPlease provide all contact information on the person(s) who contacted you (name, email, phone, etc.):PreviousNextDocumentation UploadPlease use the following section to upload any documentation you have that supports your claim. This can include, but is not limited to, an actual police report you filed, any screenshots of any conversations you had with someone else, wallet address codes, etc. If you don't have anything to upload, simply click NEXT to go to the next section. Upload Document(s) Here Click or drag files to this area to upload. You can upload up to 10 files. Signature *Type your full name in the box above.Date Signed *Choose today's date above.BY SUBMITTING THIS REQUEST, I AGREE THE INFORMATION ABOVE IS ACCURATE AND REPRESENTS ALL THE FACTS ABOUT THIS CASE AS KNOWN TO ME AT THE TIME OF SUBMISSION *I AgreeNameSubmit
