Block.one Securities Settlement - Submit a Claim Page 1

Submit a Claim - Page 1

Please select which type of Claimant you are:*

IdentityType:*

First Name:*

Middle Initial:

Last Name:*

Co-Beneficial Owner's Name (If applicable, provide all information)

First Name:

Middle Initial:

Last Name:

Beneficial Owner's Social Security Number (Last 4):*

Note: If you do not have a Social Security number, enter "9999".

Business/Entity Name:*

Representative Name:*

Taxpayer Identification Number (Last 4):*

Account Type:*

Country:*

Address Line 1:*

Address Line 2:

Address Line 3:

Address Line 4:

Address Line 5:

City:*

State:*

Province:*

ZIP Code:*

Postal Code:*

Phone Number:

Alternate Phone Number:

Email Address:*

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