Form

Full Name:

Email:

Select Country:

Phone Number:

Date of Birth:

Amount Lost:

Transaction Type:

what mode of payment was used?

Was your device hacked during the incident?

Please, tell us more:

These enables us investigate & track down the subject

Subject's Name:

Email:

Website link:

Subject's Phone Number:

Please read the following statement and ascertain your agreement by typing your full name in the box provided below:

Sign:

By digitally signing this document, I confirm that the information I provided is, to the best of my knowledge, true and accurate. I am aware that providing false information may result in a fine, imprisonment, or both.