Crypto Fraud Victim Recovery Submission Form (Public Resource)
Public Victim Support Resource
Office of Customer Education & Outreach (OCEO)
Cryptocurrency Fraud • Victim Documentation • Reporting Guidance
Crypto Fraud Victim Recovery Submission Form
This form helps victims organize case information and request a structured review.
Important Disclosure
This is a PUBLIC RESOURCE form for victim-support intake and documentation.

Not a U.S. Government form.
Not affiliated with an official federal domain unless explicitly verified by the user.
SAMPLE / PUBLIC USE
Security Notice: We will never ask for your password, one-time codes, seed phrase, or private keys. Do not pay any “release fee,” “verification tax,” or “urgent unfreeze charge” to unknown parties.
A. Victim Information
Complainant
1.Last Name
2.First Name
3.M.I.
4.Street Address
5.Apartment/Unit #
6.City
7.State/Province
8.ZIP/Postal Code
9.Country
10.Telephone
11.Alternate Phone
12.Email Address
13.Preferred Contact Method
14.Occupation (optional)
B. Authorized Representative (If Applicable)
1.Representative Name
2.Organization / Firm
3.Telephone
4.Email Address
5.Relationship to Victim
C. Subject of Report (Individual / Entity / Platform)
1.Type (check all that apply)
2.Profession / Entity Category (if known)
3.Name / Display Name
4.Website / App / Handle
5.Email (if known)
6.Phone (if known)
7.Country/Region (if known)
8.Initial Contact Method
9.If other, describe
D. Fraud Description and Loss
1.Date of Incident (approx.)
2.Is the conduct ongoing?
3.Estimated Total Loss (USD)
Fraud Category (check all that apply)
Narrative Summary
4.Provide key facts, timeline, and why you believe this was fraudulent.
E. Blockchain Transaction Details
1.Network
2.Asset / Token
3.Amount
4.Date Sent
5.Your Sending Wallet Address
6.Recipient / Alleged Scam Address
7.Transaction Hash (TXID)
8.Exchange / Platform Involved (if any)
Additional Transactions
9.List additional TXIDs, amounts, networks, and dates (or attach a list).
F. Supporting Evidence Checklist
G. Declaration
I declare that the information provided is accurate to the best of my knowledge. I understand that this submission is part of a public victim-support intake process and does not guarantee recovery outcomes.
1.Signature (typed)
2.Date