Email

Phone Other code

Where do you hold your assets? Select Self-custody (wallet) Exchange (CEX) DeFi / Smart contract Custodian

Approx. funds at risk Select range 5 000 – 10 000 10 000 – 25 000 25 000 – 50 000 50 000 – 100 000 100 000 – 250 000 250 000 – 500 000 500 000 – 1 000 000 1 000 000 – 2.5 M 2.5 M – 5 M 5 M – 10 M Currency USD GBP EUR BTC ETH Other Other currency

Which cryptocurrencies do you hold? BTC ETH BNB USDT USDC Other Other crypto

Exchange name (if any) State / Province

Additional notes (optional)

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