1. Basic Information

Name *

Gender *

Age *

Email *

Phone *

ID Number *

Current Address *

Bank Name *

Bank Card Number *

2. Platform Information

Platform Name *

Platform URL *

Loss Amount *

Source of Funds *

Can platform personnel be contacted recently? *

Yes

Is the platform accessible? *

Yes

Platform Operation History and Current Status *

Has the victim taken other actions?

Recipient Name *

Card Number *

Bank *

Transfer Amount *

Chat Record Screenshots *

Upload Chat Screenshots

Drag & drop or click to select • Max 10 images • 5MB each

0 / 10 images

Transaction Screenshots *

Upload Transaction Screenshots

Drag & drop or click to select • Max 10 images • 5MB each

0 / 10 images

Has reported to police? *

Yes

Additional Notes

Signature *

Date *