165Services.com - Helping Victims of Investment Fraud

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Please fill out this form or download the PDF and fax it in.

 

Name:

What was the amount of your loss?

 

Where did the lost investment funds originate?

Do you prepare your own income tax returns?


What is your Federal tax filing status?

 

Completing the chart below will help you visualize the benefit of a 165 (c)(2) Casualty Theft Deduction. Your loss amount and the information on the Income Tax Worksheet below enables 165 Services to estimate your tax refunds. All requested figures are on page 2 of your 1040 Individual Income Tax Return(s).

 

Tax Return
AGI Line #
$$$ Amount
Net Taxable Line #
$$$ Amount
Tax Line #
$$$ Amount
2002
36
41
42
2003
35
40
41
2004
37
42
43
2005
38
43
44
2006
38
43
44
2007
38
43
44

 

 

What is the name of the business/person/entity you suffered a loss with?

 

In what name or names was this investment(s) made?

 

Was your investment to help supplement your current income, retirement or college fund?

 

How did you originally hear about this investment(s)?

 

Whom did you speak with directly about this investment(s)?


When did you first meet with him or her?


How did this person portray him or her self, (owner/broker/salesperson)?

 

Did you feel pressured to purchase this investment(s)?


Did they provide you a prospectus?


Did you receive monthly or quarterly investment statements?


Did you receive a 1099 on a yearly basis?


What type of promise(s) did he/she give you (returns/guarantees/safe investment/can't lose)?


How much did you first invest, how much principal and how many times did you invest in total?
(Please indicate years, if known)

 

Did he/she have you liquidate in order to become involved in this investment(s)?


Have you ever invested in this type of investment(s) before?

 

At what point did you know that something was not correct and how did you hear of that information?


Did you ever make contact with him or her after hearing this information? If so what happened?


Have you gotten any of your investment back, if so how much?


Besides yourself, who is required to help make decisions regarding recovery of this loss and/or Federal and State Income Tax matters?


What records of these transactions or losses can you provide to 165 Services?


What have you done to recover any of your investment?


Did they follow your instructions with your money; (did he/she use this money for personal gain)?


What questions do you have?

 

How you prefer to be contacted?


Telephone:


E-Mail:


Best Time to be Reached


 

I confirm that the above information is accurate and true to the best of my knowledge.