— Seeking Victim Information in Pinnacle Investigation

Contact Information

Authorized Business Representative
The individual listed will be the point of contact for the duration of the investigation

First Name

Middle Name

Last Name

Best Contact Number

E-Mail Address

Victim Business

Business Name

Address Line 1

Address Line 2

City

State

ZIP Code

Tax ID

Questions

1. What dates were you a client of Pinnacle?

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2. If known, provide the specific amount of money unpaid for:

2a. State tax

2b. Federal tax (IRS)

2c. Payroll

2d. Direct deposit

2e. Money order

2f. Wire transfer

2g. If only the total loss amount is known, provide it here

3. If you answered question 2a, identify the state(s) associated with this unpaid tax balance.

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4. What method did your company use to send payroll and payroll taxes to Pinnacle? Select all that apply

Direct deposit

Money order

Wire transfer

Check

Other

4a. If other, please describe.

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5. Has your company been reimbursed by an insurance company?

Yes
No

5a. If yes, how much?

6. If you were reimbursed, did you have to pay a deductible?

Yes
No

6a. If yes, how much?

7. List any additional costs incurred by your company as a result of Pinnacle's non-payments. (e.g., attorney's fees, overdraft fees, banking fees, accounting fees, etc.)

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8. Have you been contacted by Cachet Banq regarding the recovery of some of the losses you reported above?

Yes
No

8a. If yes, how much do you expect to recover?

9. Which, if any, of the below substantial financial hardship situations applies to your experience in this matter. Select all that apply

I did not experience any substantial financial hardship.

I became insolvent.

I had to file for bankruptcy.

I suffered substantial loss of a retirement, education, or other savings or investment fund.

I had to make substantial changes to employment, such as postponing retirement plans.

I had to make substantial changes to living arrangements, such as relocating to a less expensive home.

I suffered substantial harm to the ability to obtain credit.

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 Pinnacle Investigation

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