— Jim McCanlies Investment Investigation Questionnaire

Contact Information

First Name

Middle Name

Last Name

Date of Birth

Phone Number (no dashes, spaces, or parentheses)

Email Address

Address Line 1

Address Line 2

City

State

Country

ZIP/Postal Code

Questionnaire

1. When did you first meet and/or speak with Jim McCanlies?

Year / Month / Day

2. Were you introduced or referred?

a. Introduced
b. Referred
c. Other

If other, please provide explanation:

3. Who was your point of contact regarding investing with Jim McCanlies or anyone affiliated with Jim McCanlies?

4. Who described to you the investment opportunity with Jim McCanlies?

5. How were the investment funds you provided going to be utilized?

6. Were you promised a return on investment?

Yes
No

If yes, please provide the terms:

7. Did you sign an investment contract with Jim McCanlies?

Yes
No

If yes, did you sign contract in person or via DocuSign?

a. In Person
b. DocuSign
c. Other

If other, please provide explanation:

8. How did you deliver your investment to Jim McCanlies?

If other, please provide explanation:

9. Did you authorize Jim McCanlies to transfer the funds that you provided to any other entity and/or person?

Yes
No

If yes, please state who you understood would receive the funds that you provided:

10. Other than the details you provided previously, did you authorize the investment funds provided to Jim McCanlies to be utilized for any other purpose?

Yes
No

If yes, please state the other purpose:

11. If applicable, how did you receive any disbursement of earnings or interest?

If other, please provide explanation:

12. If applicable, please describe any investment returns and/or payouts you deferred and instead elected to reinvest with Jim McCanlies.

13. Please provide the approximate amount of money that you sent to Jim McCanlies, as an investment, as of August 31, 2024. Do not include interest earned or reinvestment amounts.

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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Jim McCanlies Investment Investigation Questionnaire

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