Colorado Form Dr 2153 – Fill Out and Use This PDF

Under Victim Identification, enter your Full Legal Name: First, Middle and Last, and mark Jr., Sr. or III.

Enter the Date of Birth (MM/DD/YY), the Social Security Number and the Driver's License or Identification Card Number (PIN).

Enter the Name (If Different) When the Events Described in this Affidavit Took Place: First, Middle and Last, and mark Jr., Sr. or III.

Under Current Address, enter the Address, City, State and ZIP Code, then the Beginning Date at this Residence (MM/YY) and the Ending Date at this Residence (MM/YY).

Enter the Address (If Different) When the Events Described in this Affidavit Took Place: Address, City, State and ZIP Code, then the Beginning Date at this Residence (MM/YY) and the Ending Date at this Residence (MM/YY).

Enter the Current Daytime Telephone Number and the Current Evening Telephone Number.

Under How The Fraud Occurred, check all that apply for items 1 - 6.

1. Check this if you did not authorize anyone to use your name or personal information to seek the money, credit, loans, goods or services described in this report.

2. Check this if you did not receive any benefit, money, goods or services as a result of the events described in this report.

3. Your identification documents (for example, credit cards, birth certificate, driver's license, Social Security card, etc.) were Lost or Stolen: mark one, and enter the Date On or About Missing (MM/DD/YY).

4. For each person who, to the best of your knowledge and belief, used your information (for example, your name, address, date of birth, existing account numbers, Social Security number, mother's maiden name, etc.) or identification documents to get money, credit, loans, goods or services without your knowledge or authorization, enter the Name, Address (if known), Phone Number(s) and Additional Information.

5. Check this if you do not know who used your information or identification documents to get money, credit, loans, goods or services without your knowledge or authorization.

6. Additional comments: for example, a description of the fraud, which documents or information were used, or how the identity thief gained access to your information. Attach additional pages if necessary.

7. Check this to indicate that you are willing to assist in the prosecution of the person(s) who committed this fraud.

8. Check this to authorize the release of this information to law enforcement for the purpose of assisting them in the investigation and prosecution of the persons who committed this fraud.

9. Check this if you have reported the events described in this affidavit to the police or other law enforcement agency, and mark Yes or No for Did the police write a report?

Under Please complete the following, enter the Agency Number, Officer/Agency Personnel Taking Report, Date of Report, Report Number, If Any, Phone Number and Email Address, If Any.

Please indicate the supporting documentation you are able to provide. Attach copies (Not originals) to the affidavit: a copy of the report filed with the police or sheriff's department.

You declare under penalty of perjury that the information you have provided in this affidavit is true and correct to the best of your knowledge.

If you give a false statement, your driver's license or identification card may be canceled and denied, in accordance with § 42-2-122, C.R.S.

If you are convicted of perjury in the first or second degree, the Department shall immediately revoke your driver's license or identification card, in accordance with § 42-2-125, C.R.S.

Notary Seal: Subscribed and affirmed, or sworn to before me in the County of, State of, this day of, 20, then the Notary Signature and the Commission Expiration Date.

Take this completed, notarized form with a police report to a driver's license office to apply for a license or ID with a new number. Do Not Mail or Fax.

Knowingly submitting false information on this form could subject you to criminal prosecution for perjury.