Seeking Victim Information in the Alpha Influence Investigation

If you have been directed to this questionnaire via an FBI communication, it is because you have been identified as a possible investor in Alpha Influence, LLC. To help understand the extent and impact of investment losses we ask you to provide details about your experience. As such, please answer the questions below to the best of your ability. Based on your responses, you may be contacted by the FBI and asked to provide additional information.

Contact Information

First Name

Middle Name

Last Name

Date of Birth

Year / Month / Day

Phone Number (no dashes, spaces, or parenthesis)

E-Mail Address

Address Line 1

Address Line 2

City

State

Country

ZIP/Postal Code

Questionnaire

1. As a result of your Alpha Influence investment loss have you experienced any of the following financial hardships: Select as many as apply

None, I did not incur a loss.

I incurred a loss, but it did not have a substantial impact on my finances.

I suffered a substantial loss of my retirement, education, savings or other investment funds

I suffered a substantial harm to my ability to obtain credit

I made a substantial change to my employment, such as postponing retirement plans, returning to work after retirement or obtaining secondary employment

I made a substantial change to my living arrangements, such as relocating to a less expensive home or losing a home to foreclosure

I filed for Bankruptcy under the Bankruptcy Code (title 11, United States Code)

2. Please provide a brief explanation of how the investment loss has substantially affected your financial well-being

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Privacy Act Statement

The FBI is authorized to collect the information on this form by one or more of the following provisions: Title 28, United States Code, sections 533 and 534; Title 28, Code of Federal Regulations, section 0.85; and the Attorney General Guidelines for Victim and Witness Assistance. The information requested will assist the FBI in providing you with assistance to which crime victims are entitled under federal law. You do not have to provide the requested information; however, failure to do so may hinder the FBI in providing you with crime victim assistance. The information collected on this form is protected by the Privacy Act of 1974, as amended, Title 5, United States Code section 552a, and is maintained in the FBI’s Central Records System, DOJ/FBI-002, a description of which was published in the Federal Register at 63 Fed. Reg. 8671 (Feb. 20, 1998) and which may be viewed at www.justice.gov/opcl/doj-systems-records#doj

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Seeking Victim Information in the Alpha Influence Investigation

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