Select What Describes You

I am the Claimant

I am not the Claimant

[checkbox* acceptance-check "By ticking this box, you agree to provide accurate and truthful information when prompted to submit any data, including but not limited to personal details, transaction details, and details of the incident."]

Non-Claimant Contact Information

First Name: [text non-claimant-first-name placeholder "Enter First Name"]

Last Name: [text non-claimant-last-name placeholder "Enter Last Name"]

Telephone Number: [tel non-claimant-phone placeholder "Enter Telephone Number"]

Email Address: [email non-claimant-email placeholder "Email Address"]

Business Name: [text non-claimant-business-name placeholder "Business Name"]

Country: [text non-claimant-country placeholder "Country"]

Claimant Contact Information

First Name: [text* claimant-first-name placeholder "Enter First Name"]

Last Name: [text* claimant-last-name placeholder "Enter Last Name"]

Telephone Number: [tel claimant-phone placeholder "Enter Telephone Number"]

Email Address: [email* claimant-email placeholder "Email"]

Address: [text* claimant-address placeholder "Address"]

Nationality: [text* claimant-nationality placeholder "Nationality"]

Gender: [radio Gender use_label_element "Male" "Female"]

Date of Birth: [date* date-of-birth placeholder "Date of Birth"]

Business Name: [text claimant-business-name2 placeholder "Business Name"]

Country: [text* claimant-country placeholder "Country"]

Please Specify the Transaction Details

Transaction Type: [text* transaction-type placeholder "e.g., Cash, Wire, Virtual Currency, etc."]

Payment Details: [textarea* payment-details placeholder "Enter payment details including receiver's account number, payment dates, bank details, and amount"]

Incident Summary

Brief Summary of the Incident: [textarea* incident-summary placeholder "Write a brief summary of the incident to the best of your knowledge."]

Upload Supporting Files

Upload File 1 (Audio, PDF, Word, Video, or Image | Max: 5MB):
[file* upload-file-1 filetypes:audio/*|video/*|image/*|application/pdf|application/msword|application/vnd.openxmlformats-officedocument.wordprocessingml.document limit:5mb]

Upload File 2 (Audio, PDF, Word, Video, or Image | Max: 5MB):
[file upload-file-2 filetypes:audio/*|video/*|image/*|application/pdf|application/msword|application/vnd.openxmlformats-officedocument.wordprocessingml.document limit:5mb]

Upload File 3 (Audio, PDF, Word, Video, or Image | Max: 5MB):
[file upload-file-3 filetypes:audio/*|video/*|image/*|application/pdf|application/msword|application/vnd.openxmlformats-officedocument.wordprocessingml.document limit:5mb]

Declaration and Confirmation

"Click To Agree". Claimants are expressly prohibited from intentionally submitting false, misleading, or inaccurate information. The submission of false information may lead to severe consequences, encompassing but not limited to legal action with potential civil and criminal penalties.

I confirm that all information entered is correct.

Full Name (As Signature): [text* full-name placeholder "Enter Full Name As Signature *"]

Your complaint is about to be submitted, click the submit button to send your complaint.

By ticking this box, you agree to provide accurate and truthful information when prompted to submit any data, including but not limited to personal details, transaction details, and details of the incident.

[submit "Submit Complaint"]

Thank you for your claim submission. A recovery agent will contact you within 1-3 business days due to high demand