Digital Asset Damage Incident Report
Please enter the required details. Our team will be in contact with you shortly.
Sign in to Google to save your progress. Learn more
Date of the Incident *
Please enter the date when you first recognized the occurrence of the reported Incident.
Token Type *
Please specify the tokens and respective blockchains involved. e.g. Bitcoin, Ethereum, USDT-BSC, etc...
What kind of digital asset wallet are you using?
Please enter the name of the digital asset wallet you are using.
Amount of tokens lost (by type of digital token) *
Value of Lost Tokens (in US Dollars) *
Please enter the value of assets (in USD) that were lost as a result of this incident.
Transaction Hash(es) *
Please specify the origin transaction hashes where assets were first stolen or compromised.
Victim's Digital Asset Address *
Please provide the digital asset wallet address(es) for where assets were stolen/compromised.
Receiver Digital Asset Address *
Please provide the suspicious wallet address(es) for where the compromised funds were first transferred.
Website Information (URL)
Please enter URL information for any websites, messengers, and social media sites involved in the incident. (e.g. phishing site involved in digital asset scam.)
Nature of Reported Incident *
Please select the field(s) that best describe the Digital Asset fraud/incident you are reporting.
Civil and criminal litigation in progress. *
If you're in the progress of a civil or criminal suit, please enter this part.
Details *
Please describe the case in as much detail as possible. (e.g. Circumstances leading up to the loss of assets or any other information that you think would be useful for our investigations.)
Clear form
Never submit passwords through Google Forms.
This form was created inside of Uppsala Security. Report Abuse