iCap Investigation Questionnaire

If you have been directed to this questionnaire via an FBI communication, it is because you have been identified as a potential investor in one or more iCap entities. 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

Phone Number (no dashes, spaces, or parentheses)

Email Address

Address Line 1

Address Line 2

City

State

Country

ZIP/Postal Code

Questionnaire

1. Have you invested in any iCap entities or other companies affiliated with Chris Christensen?

Yes
No

2. How did you hear about iCap?

3. Please provide the date of your initial investment in MM/DD/YYYY format:

4. Which iCap entity(ies) did you invest in?

5. Please provide the total dollar amount invested:

6. Please provide the total dollar amount of your investment that was not repaid to you:

7. Please provide the names of all iCap representatives you were in contact with:

8. What claims, if any, did iCap representatives make about the return on investment?

9. Do you have copies of any communications with iCap, promotional materials provided by iCap, or copies of financial transactions made as part of your investment in iCap?

Yes
No

10. Are you currently represented by an attorney in connection with this matter? If so, please provide the attorney’s name and contact information:

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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iCap Investigation Questionnaire

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