Ftc Identity Theft Affidavit – Fill Out and Use

(1)My full legal name: ________________________________________________

(2)My date of birth: __________________

mm/dd/yyyy

(3)My Social Security number: ________-______-__________

(5)My current street address:

____________________________________________________________________________

Number & Street NameApartment, Suite, etc.

_______________________________________________________________

(6)I have lived at this address since ____________________

mm/yyyy

(7)My daytime phone: (____)___________________

My evening phone: (____)___________________

My email: ______________________________________

Leave (3) blank until you provide this form to someone with

alegitimate business need, like when you are filing your report at the police station or sending the form

to a credit reporting agency to correct your credit report.

(8)My full legal name was: ____________________________________________

(9)My address was: _________________________________________________

Skip (8) - (10) if your information has not changed since the fraud.

(15)Additional information about the crime (for example, how the identity thief gained access to your information or which documents or information were used):

________________________________________________________________

________________________________________________________________

________________________________________________________________

(14)and (15): Attach additional sheets as needed.

Documentation

(16)I can verify my identity with these documents:

A valid government-issued photo identification card (for example, my driver’s license, state-issued ID card, or my passport).

If you are under 16 and don’t have a photo-ID, a copy of your birth certificate or a copy of your official school record showing your enrollment and legal address is acceptable.

Proof of residency during the time the disputed charges occurred, the loan was made, or the other event took place (for example, a copy of a rental/lease agreement in my name, a utility bill, or an insurance bill).

(16): Reminder: Attach copies of your identity documents when sending this form to creditors

and credit reporting agencies.

___________________________________________________________________

Name of InstitutionContact Person Phone Extension

___________________________________________________________________

Select ONE:

This account was opened fraudulently.

This was an existing account that someone tampered with.

___________________________________________________________________

Date Opened or Misused (mm/yyyy) Date Discovered (mm/yyyy) Total Amount Obtained ($)

___________________________________________________________________

Name of InstitutionContact Person Phone Extension

___________________________________________________________________

Select ONE:

This account was opened fraudulently.

This was an existing account that someone tampered with.

___________________________________________________________________

Date Opened or Misused (mm/yyyy) Date Discovered (mm/yyyy) Total Amount Obtained ($)

___________________________________________________________________

Name of InstitutionContact Person Phone Extension

___________________________________________________________________

Select ONE:

This account was opened fraudulently.

This was an existing account that someone tampered with.

___________________________________________________________________

Date Opened or Misused (mm/yyyy) Date Discovered (mm/yyyy) Total Amount Obtained ($)

(19):

If there were more than three frauds, copy this page blank, and attach as many additional copies as necessary.

Enter any applicable information that you have, even if it is incomplete or an estimate.

If the thief committed two types of fraud at one company, list the company twice, giving the information about the two frauds separately.

Contact Person: Someone you dealt with, whom an investigator can call about this fraud.

Account Number: The number of the credit or debit card, bank account, loan, or other account that was misused.

Dates: Indicate when the thief began to misuse your information and when you discovered the problem.

Amount Obtained: For instance, the total amount purchased with the card or withdrawn from the account.

Your Law Enforcement Report

(20)One way to get a credit reporting agency to quickly block identity theft- related information from appearing on your credit report is to submit a detailed law enforcement report (“Identity Theft Report”). You can obtain an Identity Theft Report by taking this form to your local law enforcement office, along with your supporting documentation. Ask an officer to witness your signature and complete the rest of the information in this section. It’s important to get your report number, whether or not you are able to file in person or get a copy of the official law enforcement report. Attach a copy of any confirmation letter or official law enforcement report you receive when sending this form to credit reporting agencies.

Select ONE:

I have not filed a law enforcement report.

I was unable to file any law enforcement report.

I filed an automated report with the law enforcement agency listed below.

I filed my report in person with the law enforcement officer and agency listed below.

____________________________________________________________________

Law Enforcement DepartmentState

(20):

Check “I have not...” if you have not yet filed a report with law enforcement or you have chosen not to. Check “I was unable...” if you tried to file a report but law enforcement refused to take it.

Automated report:

Alaw enforcement report filed through an automated system, for example, by telephone, mail, or the Internet, instead of a face-to-face interview with a law enforcement officer.