Berg PC — Case Registration Form

Client Profile

Personal & Contact Information

Full Legal Name *

Date of Birth *

Phone Number *

Email Address *

Residential Address *

Occupation

Government ID / SSN *

Estimated Financial Loss (USD) *

Case Information

Incident & Transaction Details

Fraudulent Platform / Investment Entity *

Website / URL Associated with the Incident

Transaction Method & Payment Information *

Case Reference Number

Date of First Transaction

Date of Last Transaction

Would you like us to assist you in filing a police report?

Yes, please assist me No, not at this time Already filed

Case Narrative

Detailed Account of Events

Please describe the incident in your own words *

How did you first encounter this platform?

Do you have supporting documentation?

Additional notes or concerns

Supporting Documents

If you have transaction records, screenshots, bank statements, or chat logs, please email them to tomas.f.tijerina@bergpclawfirms.com with your full legal name in the subject line, after submitting this form.

Client Acknowledgement

Certification & Authorization

I hereby certify that the information provided within this intake form is accurate and complete to the best of my knowledge. I understand that Berg PC reserves the right to decline or terminate representation should any submitted information be materially false or misleading.

Client Certification — Required

I acknowledge that the information submitted in this form is confidential and will be used solely for the purpose of legal evaluation and representation by Berg PC Attorneys at Law.

Privacy Acknowledgement — Required

Date *

Attorney of Record

Tomas Tijerina

Consultant Lawyer · Berg PC Attorneys at Law

Client Signature *

Registration Submitted

Thank you. Your case registration has been officially received and filed by Berg PC Attorneys at Law. Your assigned attorney will contact you upon completing your case record to confirm receipt and outline the next steps.

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