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Full Name
Date of Birth
Email
Phone Number
What payment method did you use?
Please select
Interac e-Transfer
Wire Transfer
Credit/Debit Card
Cryptocurrency
Other
How much money did you send?
Please select
$0 – $5,000
$5,001 – $10,000
$10,001 – $25,000
$25,001 – $50,000
$50,001 – $100,000
$100,001 – $250,000
$250,000+
Have you previously tried to recover the lost funds?
Please select
Yes
No
Preferred time for a call with the fraud investigator?
Password
Confirm Password
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