Shopin Restitution Claim Submission

The purpose of this form is to collect information about individuals who invested in Shopin, Inc. (“Shopin”), who may be entitled to some restitution. Please carefully follow all instructions and answer the following questions accurately. If you invested multiple times, fill out this form multiple times, once for each investment. Completing a claim form does not guarantee that you will receive restitution.

Information about you

We need to know information about you in order to verify that you invested in Shopin and to communicate with you throughout the claim process.

First name

Last name

IMPORTANT: Enter the email address you used to correspond with Shopin or, alternatively, your syndicate of investors. We will be contacting you using this email address.

When you made your investment, did you live in the United States?

Yes

Please choose the country that you lived at the time of investment.

Please indicate your address at the time of your investment

Address

Address 2

City

State/Province/Region

Zip

Please upload a bill that includes your name and address at the time of your investment.

One file only.
15 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx.

Please identify whether you fall into any of the following categories.

Former or current Shopin employee

Former or current syndicate leader/administrator

Employee of vendor that provided services to Shopin

None of the above

What is/was your title at Shopin?

What was the name of syndicate?

What was your role in the syndicate?

What is the name of the vendor you worked for?

What was your position at the vendor?

Documentation of your investment

You will be required to submit this documentation to the OAG.

Did you receive a SAFT (Simple Agreement for Future Tokens)?

Yes

Please describe any documentation you may have that pertains to your purchase of Shopin tokens.

Examples of documentation substantiating your investment could include:

A contract, other than a SAFT, that you signed in order to formalize your agreement to purchase tokens.
Email communications with Shopin that discuss the terms of your investment.
Email communications with a syndicate that discuss the terms of your investment.
Investment confirmation email from either Shopin or your syndicate.

Please upload the documentation described above.

One file only.
15 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx.

Did you use DocuSign to sign your SAFT?

Yes

What is the DocuSign envelope ID associated with your SAFT?

What email address did you use to DocuSign the SAFT?

Please upload your executed DocuSign SAFT.

One file only.
15 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx.

Please upload your executed SAFT

One file only.
15 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx.

Information about your investment

How did you invest in Shopin?

Directly invested in ICO (i.e. no middle man)

Through a syndicate

What was the dollar amount of your investment in U.S. currency?

Syndicate information

What is the name of the syndicate?

What is the name of the sydicate lead, or primary contact person at the syndicate?

Enter their name in the following format: Last Name, First Name
EX: John Michael Philips would be: Philips, John

If you invested in a syndicate, but did not interact with anyone at the syndicate, enter none
If you interacted with multiple people, insert their names separated by commas

What is the email address of the syndicate leader or your primary contact person at the syndicate?

If you invested in a syndicate but did not interact with anyone at the syndicate, enter none
If you interacted with multiple people, insert their email addresses separated by a comma in the same order you entered their names for the question above.

Please explain how the process of investing currency and receiving tokens worked in your syndicate.

By choosing “Yes” below, you indicate your understanding that, in the next section, you should NOT provide information about your syndicate’s transfer of funds to Shopin. ONLY provide information about your personal transfer of funds to the syndicate.

Yes

Investment transaction details

In what currency did you make your Shopin ICO investment?

Ether (A.K.A. ETH, Ethereum)

Bitcoin (BTC)

Other…

Bitcoin/Etherium Investments

What is the transaction hash (A.K.A transaction number) for your investment?

How much did you invest? *

Enter the amount in the native currency
Include as many decimal places as possible, up to eight (8)
DO NOT convert to another currency, such as U.S. dollars
DO NOT add trailing zeroes

EX: If you invested 4.123456789 BTC, enter: 4.12345678

EX: If you invested 4.12345 ETH, enter: 4.12345

On what date did you send your investment? *

Input the date of the transaction in UTC time zone. You can find this using a block explorer, such as https://www.etherscan.io

What is the cryptocurrency address (A.K.A account number) FROM which you sent your investment?

i.e. What is the cryptocurrency address you used to invest?

What is the cryptocurrency address (A.K.A account number) TO which you sent your investment?

If you invested directly with Shopin, enter the cryptocurrency address (account number) to which Shopin asked you to send the currency here. If you invested through a syndicate, enter the syndicate's cryptocurrency address (account number) here.

Other cryptocurrency investments

Please explain how you invested using the currency you indicated in the previous section.

Please provide as much information as possible, as this will make it more likely that we are able to verify your investment.

How much did you invest?

Enter the amount in the native currency
Include as many decimal places as possible, up to eight (8)
DO NOT convert to another currency, such as U.S. dollars
DO NOT add trailing zeroes

EX: If you invested 4.123456789 BTC, enter: 4.12345678

EX: If you invested 4.12345 ETH, enter: 4.12345

On what date did you send your investment?

Input the date of the transaction in UTC time zone. You can find this using a block explorer, such as https://www.etherscan.io

What is the unique identifier for your investment? (if applicable)

FROM which account did you send your investment (if applicable)?

TO which account did you send your investment (if applicable)?

Did you receive reimbursement for your investment at any point?

Yes, complete reimbursement

Other…

Certification

I certify that the above submission is true and accurate to the best of my knowledge and that any documents attached are true and accurate copies of the originals.

Full name certification