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Personal Info

Business Info

Transaction

Subject Info

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Personal Information

Were you the victim in this incident? *

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Name

Age

Address *

Address (continued)

Suite/Apt./Mail Stop

City *

County

Country *

State

Zip Code/Route *

Phone Number *

Email Address *

Best Way To Contact You *

Others (Please Specify)

Business Information

Is the victim a business that was targeted by a Cyber incident?

Business Name

Is the incident currently impacting business operations?

Business IT POC, if applicable

Other Business POC, if applicable

Transaction Details

Transaction Type *

Was the money sent? *

Transaction Amount *

Currency

Transaction Date *

Your Bank Information (Source of Funds)

Bank Name

Account Number

Routing Number

Bank Address

Bank City

Bank State

Bank Country

Recipient Bank Information (Where Funds Were Sent)

Bank Name

Account Holder Name

Account Number

Routing Number

SWIFT/BIC Code

Bank Address

Bank City

Bank Country

Cryptocurrency Details

Cryptocurrency Type

Network/Blockchain

Exchange/Platform Used

Your Wallet Address (Source)

Recipient Wallet Address (Scammer's)

Transaction Hash/ID

Card Details

Card Network

Last 4 Digits of Card

Card Issuing Bank

Merchant Information

Merchant/Business Name

Merchant Website

Have you filed a chargeback?

Chargeback Date (if applicable)

Gift Card Details

Gift Card Type

Total Gift Card Amount

Card Serial Numbers/Codes (if available)

Where did you purchase the cards?

How were codes shared with scammer?

Cash Transaction Details

How was cash delivered?

Pickup/Drop Location (if applicable)

Description of Person Who Received Cash

Other Payment Method Details

Please provide as much detail as possible about the payment method used in the incident description below.

Description of Incident *

Subject Information

Law enforcement or regulatory agencies may desire copies of pertinent documents or other evidence regarding your complaint. Originals should be retained for use by law enforcement agencies.

Name

Business Name

Address

City

Country

State

Zip Code/Route

Phone Number

Email Address

Website

IP Address

Privacy & Signature: I certify that the information provided in this complaint is true and accurate to the best of my knowledge. I understand that providing false information may result in legal consequences. I authorize the Global Financial Fraud Watch to process this complaint and share relevant information with law enforcement agencies as necessary.

Type Your Full Name as Signature *