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Transaction ID (if known)

Transaction date

Transaction amount

Your full name, as it is written on the card.

First 6 digits of the payment card that was used for this transaction.

Last 4 digits of the payment card that was used for this transaction.

Besides you, who else has access to your personal information?

Was any of your personal information stolen? If yes, please specify which information.

Have you ever purchased cryptocurrency yourself? If yes, when was that last time you made a transaction?

Did you issue this transaction yourself?

Did you use a personal wallet address that only you have an access to?

Were you attempting to purchase any merchandise or services with your cryptocurrency payment?

What is the name of the person/company that scammed you?

Any additional information.

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