Ftc Identity Theft Affidavit PDF Details

Identity theft is a serious crime that can result in significant financial losses for victims. If you believe you have been a victim of identity theft, the Federal Trade Commission (FTC) recommends filing an identity theft affidavit. The FTC Identity Theft Affidavit can help you document the crime and provide information to law enforcement and creditors. The affidavit can also help you start the recovery process by creating a record of the incident. For more information on how to file an FTC Identity Theft Affidavit, visit the FTC website.

You can find more details concerning the ftc identity theft affidavit by looking through the listing we compiled.

QuestionAnswer
Form NameFtc Identity Theft Affidavit
Form Length6 pages
Fillable?Yes
Fillable fields133
Avg. time to fill out28 min 10 sec
Other namesftc id theft, id theft complaint, ftc complaint form gov, complaint ftc gov form

Form Preview Example

Average time to complete: 10 minutes

Identity Theft Victim’s Complaint and Affidavit

A voluntary form for filing a report with law enforcement, and disputes with credit reporting agencies and creditors about identity theft-related problems. Visit ftc.gov/idtheft to use a secure online version that you can print for your records.

Before completing this form:

1.Place a fraud alert on your credit reports, and review the reports for signs of fraud.

2.Close the accounts that you know, or believe, have been tampered with or opened fraudulently.

About You (the victim)

Now

(1)My full legal name: ________________________________________________

First

Middle

Last

Suffix

(2)My date of birth: __________________

mm/dd/yyyy

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

(4)

My driver’s license: _________

___________________

 

State

Number

(5)My current street address:

____________________________________________________________________________

Number & Street NameApartment, Suite, etc.

_______________________________________________________________

City

State

Zip Code

Country

(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.

At the Time of the Fraud

(8)My full legal name was: ____________________________________________

First

Middle

Last

Suffix

(9)My address was: _________________________________________________

Number & Street Name

Apartment, Suite, etc.

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

_______________________________________________________________

City

State

Zip Code

Country

(10)My daytime phone: (____)_________________ My evening phone: (____)_________________

My email: _____________________________________

The Paperwork Reduction Act requires the FTC to display a valid control number (in this case, OMB control #3084-0047)

before we can collect – or sponsor the collection of – your information, or require you to provide it.

Victim’s Name _______________________________ Phone number (____)_________________ Page 2

About You (the victim) (Continued)

Declarations

(11)

I

did

OR

did not

authorize anyone to use my name or personal information to

 

 

 

 

 

obtain money, credit, loans, goods, or services — or for any

 

 

 

 

 

other purpose — as described in this report.

(12)

I

did

OR

did not

receive any money, goods, services, or other benefit as a

 

 

 

 

 

result of the events described in this report.

(13)

I

am

OR

am not

willing to work with law enforcement if charges are brought

 

 

 

 

 

against the person(s) who committed the fraud.

About the Fraud

(14) I believe the following person used my information or identification

(14):

Enter what

documents to open new accounts, use my existing accounts, or commit other

you know

fraud.

 

 

 

about anyone

 

 

 

 

you believe

Name: ___________________________________________________

was involved

(even if you

First

Middle

Last

Suffix

don’t have

 

 

 

 

Address: __________________________________________________

complete

information).

Number & Street Name

Apartment, Suite, etc.

 

__________________________________________________________

 

City

State

Zip Code

Country

 

Phone Numbers: (____)_______________ (____)________________

Additional information about this person: _____________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Victim’s Name _______________________________ Phone number (____)_________________ Page 3

(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.

About the Information or Accounts

(17)The following personal information (like my name, address, Social Security number, or date of birth) in my credit report is inaccurate as a result of this identity theft:

(A)__________________________________________________________________________

(B)__________________________________________________________________________

(C)__________________________________________________________________________

(18)Credit inquiries from these companies appear on my credit report as a result of this identity theft:

Company Name: _______________________________________________________________

Company Name: _______________________________________________________________

Company Name: _______________________________________________________________

Victim’s Name _______________________________ Phone number (____)_________________ Page 4

(19)Below are details about the different frauds committed using my personal information.

___________________________________________________________________

Name of InstitutionContact Person Phone Extension

___________________________________________________________________

Account Number

 

Routing Number

Affected Check Number(s)

Account Type:

Credit

Bank

Phone/Utilities

Loan

 

 

Government Benefits

Internet or Email

Other

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

___________________________________________________________________

Account Number

 

Routing Number

Affected Check Number(s)

Account Type:

Credit

Bank

Phone/Utilities

Loan

 

 

Government Benefits

Internet or Email

Other

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

___________________________________________________________________

Account Number

 

Routing Number

Affected Check Number(s)

Account Type:

Credit

Bank

Phone/Utilities

Loan

 

 

Government Benefits

Internet or Email

Other

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.

Victim’s Name _______________________________ Phone number (____)_________________ Page 5

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

____________________________

_____________________

Report Number

Filing Date (mm/dd/yyyy)

(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.

____________________________________________________________________

Officer’s Name (please print)Officer’s Signature

____________________________

(____)_______________

 

 

Badge Number

Phone Number

 

 

Did the victim receive a copy of the report from the law enforcement officer?

Yes OR

No

Victim’s FTC complaint number (if available): ________________________

 

 

Victim’s Name _______________________________ Phone number (____)_________________ Page 6

Signature

As applicable, sign and date IN THE PRESENCE OF a law enforcement officer, a notary, or a witness.

(21)I certify that, to the best of my knowledge and belief, all of the information on and attached to this complaint is true, correct, and complete and made in good faith. I understand that this complaint or the information it contains may be made available to federal, state, and/or local law enforcement agencies for such action within their jurisdiction as they deem appropriate. I understand that knowingly making any false or fraudulent statement or representation to the government may violate federal, state, or local criminal statutes, and may result in a fine, imprisonment, or both.

_______________________________________

_________________________________________

Signature

Date Signed (mm/dd/yyyy)

Your Affidavit

(22)If you do not choose to file a report with law enforcement, you may use this form as an Identity Theft Affidavit to prove to each of the companies where the thief misused your information that you are not responsible for the fraud. While many companies accept this affidavit, others require that you submit different forms. Check with each company to see if it accepts this form. You should also check to see if it requires notarization. If so, sign in the presence of a notary. If it does not, please have one witness (non-relative) sign that you completed and signed this Affidavit.

_______________________________________

Notary

Witness:

_______________________________________

_________________________________________

Signature

Printed Name

_______________________________________

_________________________________________

Date

Telephone Number

How to Edit Ftc Identity Theft Affidavit Online for Free

Filling out ftc affidavit is simple. We designed our software to really make it user-friendly and uncomplicated and allow you to prepare any form online. Here are a few steps that you need to go through:

Step 1: Click the button "Get form here" to open it.

Step 2: So you're on the document editing page. You may change and add content to the file, highlight specified content, cross or check particular words, insert images, sign it, delete unneeded areas, or take them out completely.

Type in the required information in each segment to complete the PDF ftc affidavit

stage 1 to writing ftc complaint id theft

Write down the required particulars in the section AttheTimeoftheFraud, MyfulllegalnamewasSuffix, Middle, Last, First, MyaddresswasApartmentSuiteetc, NumberStreetName, ZipCode, Country, State, City, MydaytimephoneMyeveningphone, and Myemail.

Entering details in ftc complaint id theft part 2

It is essential to write certain details within the segment VictimsNamePhonenumberPage, AboutYouthevictimContinued, Declarations, and AbouttheFraud.

Finishing ftc complaint id theft part 3

The Name, Suffix, Last, First, Middle, AddressApartmentSuiteetc, NumberStreetName, ZipCode, Country, State, City, and PhoneNumbers space is the place where each side can insert their rights and obligations.

stage 4 to finishing ftc complaint id theft

Finalize the document by looking at the following fields: .

ftc complaint id theft  fields to fill out

Step 3: After you've selected the Done button, your form will be ready for transfer to any electronic device or email address you identify.

Step 4: Generate copies of your form - it may help you keep away from possible future challenges. And don't worry - we cannot disclose or see your details.

Watch Ftc Identity Theft Affidavit Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .