Basic Information
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you a company or individual?
Company
Individual
What is your Kroll customer code number?
*
If you don’t know your Kroll customer code number, please check your email for a message from ftx@noticing.ra.kroll.com
What type of entity is your company?
Please Select
Corporation
General Partnership
Limited Liability Company
Limited Liability Partnerships
Sole Proprietorship
Full Legal Name of Organization
What is your role at the organization?
Is your company still in business or in the process of unwinding or dissolution?
Where are you domiciled and/or regulated?
Domiciled
Regulated
Claim Assessment
Is your account monitored by a third party administrator or auditor?
Yes
No
Please state who and if they have records of your accounts and are willing to make statements in support of your claim.
Did you have a credit line with FTX?
Yes
No
How much was the credit line for?
Was the credit line in usage at the point of bankruptcy?
Yes
No
Please upload your credit line agreement.
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Have you ever received investment from FTX or one of its associates or affiliates?
Yes
No
Have you ever invested in FTX or one of its affiliated companies?
Yes
No
Do you or your entity have any ongoing litigation or unpaid claims or judgment against you?
Yes
No
Please explain.
Did you have any other side agreements with FTX?
Yes
No
Please upload any side agreements with FTX.
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Have you received any notice or contest from Kroll on the Bahamian Liquidators with respect to your claim?
Yes
No
Have you filed a proof of claim with Kroll?
Yes
No
Have you filed a proof of claim with the Bahamian liquidators?
Yes
No
What percentage of your claim would you be comfortable executing against?
Upload any screenshots, balance downloads or other forms of evidence to support your claim.
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Deposits & Withdrawals (Last 90 Days)
What was your notional amount of deposits (US dollars) in the last 90 days?
What was your notional amount of withdrawals (US dollars) in the last 90 days?
Please upload any supporting documentation showing deposits and withdrawals from the last 90 days. (i.e. excel spreadsheet or ledgers showing deposits and withdrawals)
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Notes
Please add in any additional notes or comments you would like us to know.
Do you have any other requirements you would ask of buyers in the sale of your claim?
Additional comments / notes
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