Digital Asset Claim Form

Form reference: 379381

Claim reference number:

Date submitted:

Submission channel:

Please complete every section in full. Incomplete forms may delay processing your claim. Return this form together with the required supporting documents listed in Section 4.

1. Claimant details

Full legal name:

Date of birth:

Nationality:

Country of residence:

Email address:

Phone number:

Government ID type & number:

2. Assets being claimed

Asset type:

Approximate amount:

3. Receiving wallet details

Bitcoin receiving address:

Ethereum receiving address:

Solana receiving address:

Digital Asset Claim Form

4. Supporting documents (please attach)

Any supporting documentation relevant to your claim

Documents attached to this claim:

PDF, JPG, JPEG or PNG. Up to 10 MB per file.

5. Declaration

By signing this form, I declare that:

The information provided in this form is true, complete, and accurate to the best of my knowledge.

The funding details provided in Section 3 are accurate and relate to funds sent by me.

I understand that submitting this form does not guarantee release of any assets, and that all claims are subject to verification by the Company or its administrator.

I understand that knowingly providing false information, or providing an incorrect wallet address may result in the rejection of this claim, delay in processing, and/or referral to the relevant authorities.

Electronic signature

Signature

Sign with a mouse, finger or stylus.

Full name (printed)

Date

Completed claim form submitted to Crystal Intelligence under claim reference .

Digital Asset Claim Form

6. For office use only

Date received

Verified by

Claim outcome

This section is completed by Crystal Intelligence and is left blank on your copy.

No claim reference entered

All fields are optional — download your completed form as a PDF at any time.