The United States Department of Justice - United States Attorney's Office

AdSurfDaily/ASDCashgenerator/Golden Panda (ASD)

Former Member Information Form

Today's Date:
Name:
Email Address:
Home Address:
Home telephone:
Cell Phone:
Business Name:
Business address:
Business Phone:
Name used to purchase "ad packages":
Website "ad packages" were purchased from (choose all that apply):	www.adsurfdaily.com www.asdchashgenerator.com www.lafuentedinero.com www.goldenpandaadbuilder.com
Total amount of funds you sent to ASD:
Date(s) funds sent to ASD:
Method used to send funds to ASD (direct deposit, money order, cashier's check, e-Gold, etc.):
If you deposited cash, a check or a money order to an ASD account at a Bank of America Branch, what Bank of America location did you use (provide street address and city):
Amount of money you received from ASD:
Did you advertise a Website or Company on ASD?	Yes No
If so, what Website or Company did you advertise on ASD?
Any other information?

* The United States has seized property, through a civil lawsuit, that appears to have been collected by ASD and related entities in what the government alleges was a wire fraud. It will take time to resolve this lawsuit and, even if the government prevails in its allegations, many participants will have lost money. You are providing the above information to the U.S. Attorney's Office in Washington D.C. voluntarily. By completing this form, you consent to this information being used by the U.S. Attorney's Office and other law enforcement agencies participating in this matter.