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Step
1
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Name
*
First
Last
Phone
*
Email
*
How did you obtain your bitcoin wallet address? (QR Barcode)
*
Someone sent/provided it to me
Mobile Wallet App
Online Exchange
Printed Paper Wallet from ATM
I Don't Know
What is the purpose of your transaction?
*
Investment
Buy Goods Online
Send Money to Someone
Pay a Bill
IRS, Law Enforcement, US Marshall
Next
Social Security Number (SSN)
*
Occupation
*
Bill Pay Details
Please describe the type of investment.
*
Please describe how you were contacted by the IRS, Law Enforcement, or the US Marshall.
*
Please describe how you were contacted to pay this bill.
Who is the person that provided you with the wallet or that your sending the funds to?
*
Significant Other
Fiance
Spouse
Friend
Relative
Other
What is his/her name?
*
First
Last
What country is the person receiving the bitcoin located in? (i.e. Nigeria, Italy)
*
Select One
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Congo-Brazzaville)
Costa Rica
Croatia
Cuba
Cyprus
Czechia (Czech Republic)
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (fmr.
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (formerly Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestine State
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Other
What is the family relationship? (e.x. aunt, cousin)
*
How long have you known them?
*
How did you meet?
*
Have you met face to face? (In Person)
Yes
No
When was the last time you saw each other?
*
What is the total amount of money you plan on sending to this person?
*
What is the source of funds being used to make this purchase?
*
Personal Savings
You Received Cash
Income / Salary
You Received a Wire Transfer
You Received a Check
Please describe the purpose of the funds:
*
What is your expected monthly volume of purchases to this wallet?
*
$0 - $2,999
$3,000 - $9,999
$10,000 - $49,999
$50,000+
Consent
*
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