— Seeking Victim Information in the 245C-NY-3791162 Investigation

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. Were you solicited for investments into your timeshare?

Yes
No

2. When were you first contacted about this opportunity?

Year / Month / Day

3. By whom were you first contacted? Please provide name and any known contact information, such as address, work or cell phone, e-mail, etc.

characters remaining

4. Information related to timeshare investment?

Investment 1

a. Company Funds were to be sent on to:

b. Wiring Information:

i. Bank account/Crypto Wallet Address:

ii. Reference Identifier:

iii. Notes:

iv. Amounts

Investment 2

a. Company Funds were to be sent on to:

b. Wiring Information:

i. Bank account/Crypto Wallet Address:

ii. Reference Identifier:

iii. Notes:

iv. Amounts:

Investment 3

a. Company Funds were to be sent on to:

b. Wiring Information:

i. Bank account/Crypto Wallet Address:

ii. Reference Identifier:

iii. Notes:

iv. Amounts:

5. What was your total loss amount? What was the time period the loss amount was accrued? Note: Total loss amount does not include any anticipated or promised interest or return on your investment. The total loss amount is the amount of principal invested minus any monies returned to you by the investment program under investigation.

6. As a result of this offense, I have: Please select all that apply

Become insolvent; 

Filed for bankruptcy under the Bankruptcy Code (title 11, United States Code); 

Suffered loss of a retirement, education, or other savings or investment fund; 

Made changes to my employment (such as postponing retirement plans); 

Made changes to my living arrangements (such as relocating to a less expensive home); 

Suffered harm to my ability to obtain credit.

7. Are you willing to be further interviewed by law enforcement as a part of this investigation?

Yes
No

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 245C-NY-3791162 Investigation

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