Cryptocurrency Exchange Law Enforcement Information Request Form
Use this form to submit a law enforcement information request to the cryptocurrency exchange. Provide the agency details, officer contact information, case reference, requested record scope, and any supporting documents needed to process the request.
Requesting Agency and Officer
Requesting Agency Name
*
Department or Unit
Officer Name
*
First Name
Middle Name
Last Name
Officer Email
*
example@example.com
Officer Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Badge or Case-Assigned Identifier
Case and Request Details
Case or Reference Number
*
Request Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Request Type
*
Account Information
Transaction History
Address Information
Other Records Request
Request Priority / Urgency
Please Select
Routine
Time-Sensitive
Urgent
Immediate Response Requested
Legal or Process Basis
*
Subject or Account Information
Exchange Username
Account Handle
Wallet Address
Transaction Hash
Known Date Range
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Information Requested and Scope
Specific Records Requested
*
Account registration details
Access logs
Transaction history
Withdrawal history
Deposit history
Linked wallet activity
Communications or notices
Other
Record Date Range Start
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Record Date Range End
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Limitations or Notes on Scope
Delivery and Supporting Documents
Preferred Delivery Method
*
Secure Email
Secure Portal
Courier
Other
Secure Return Contact or Portal Details
*
Supporting Documents
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Internal Processing Notes
Submit Request
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