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 5.

1. Claimant details

Full legal name:

Date of birth:

Nationality:

Country of residence:

Email address:

Phone number:

2. Assets being claimed

Asset type:

Approximate amount:

3. Original funding details

How were the funds originally sent?

Digital Asset Claim Form

4. Trading losses

Approximately how much have you lost over the course of your trading experience using your own funds or capital?

$5,000–$10,000

$10,000–$30,000

$50,000–$100,000

$100,000 or more

5. Supporting documents (please attach)

Any supporting documentation relevant to your claim

Documents attached to this claim:

1.
2.
3.

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

6. 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.

Claim form issued by Crystal Intelligence. Complete every section, sign, and return with the supporting documents listed in Section 5.

Digital Asset Claim Form

Electronic signature

Signature

Sign with a mouse, finger or stylus.

Full name (printed)

Date

7. For office use only

Date received

Verified by

Claim outcome

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