Cryptocurrency ATM Operator Complaint Form

Title:

*

Mr.

Mrs.

Ms.

First Name:

*

Last Name:

*

Address:

*

City:

*

State:

*

Zip Code:

*

Email Address:

*

(Do not add space or punctuation after email address)

Confirm Email Address:

*

This needs to match the value of the previous field.

Phone:

*

Yes, I consent to receive SMS messages to the above telephone number.(?)

By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.

Age:

*

Cryptocurrency ATM Operator:

Company or Individual's Address:

Company or Individual's City:

Company or Individual's State:

Company or Individual's Zip Code:

Email Address (if available):

Any addtional details (if applicable):

Number of Transactions:

Transaction Date(s):

Transaction Dollar Amount(s):

Method(s) of Payment:

Have you contacted the cryptocurrency ATM operator?:

Yes

No

Choose the action you believe the cryptocurrency ATM operator is doing that does not comply with law:

Not honoring refund

Not providing receipt

Not providing written disclosures prior to any transaction, including

Charging fees greater than $5 or 15% of the value of the cryptocurrency being bought

Describe what you believe the cryptocurrency ATM operator is doing that does not comply with law:

*

If mailing attachments:

Please check if you are separately mailing supporting documents (send copies and retain originals)