Seeking Victims Information in Crypto Fraud Investigation

Crypto Fraud Investigation Questionnaire

If you have been directed to this questionnaire via an FBI communication, it is because you have been identified as a potential target of a phishing and crypto fraud scheme.

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
For the below questionnaire, please only fill this form out on behalf of yourself, or if you are the Guardian or Next of Kin of a potential victim. If you know someone else that may be a potential victim and they are neither a minor nor deceased, please encourage them to fill out this form on their own behalf.

1. Have you lost cryptocurrency from your account due to a supposed customer service representative reaching out to you to entice you to log into your account and/or move your cryptocurrency to another wallet?

Yes
No

2. Please provide the date of your loss in MM/DD/YYYY format:

3. Please provide the total cryptocurrency amount loss: (e.g., 0.0015 BTC, 1.2 ETH, etc)

4. Please utilize the following questions to provide the following information for the first ‘customer service’ representative contact you had:

a) Date of the contact:

b) Name of the customer rep:

c) Type of contact: 

d) Phone number they called/texted from:

e) Their email address:

f) Full webpage link provided: 1234-coinbase[.]com, etc

g) Duration of the call:

5. Please utilize the following questions to provide the following information for the second ‘customer service’ representative contact you had:

a) Date of the contact:

b) Name of the customer rep:

c) Type of contact: 

d) Phone number they called/texted from:

e) Their email address:

f) Full webpage link provided: 1234-coinbase[.]com, etc

g) Duration of the call:

6. Please utilize the following questions to provide the following information for the third ‘customer service’ representative contact you had:

a) Date of the contact:

b) Name of the customer rep:

c) Type of contact:

d) Phone number they called/texted from:

e) Their email address:

f) Full webpage link provided: 1234-coinbase[.]com, etc

g) Duration of the call:

If you’ve had additional contact you would like to report, please email RHCryptoFraud@fbi.gov in the same format as above.

8. Please provide any additional information that you believe would be helpful:

characters remaining

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

Captcha

Official websites use .gov

Secure .gov websites use HTTPS

Seeking Victims Information in Crypto Fraud Investigation

fbi

federal bureau of investigation

FBI.gov Contact Center

Email updates