Sample Identity Theft Affidavit Template
Below is a copy of sample letter you can use as a template for identity theft
declaration.
Name __________________________________
Phone number _______________________
ID Theft Affidavit
Victim Information
My full legal name is
___________________________________________________________
(First) (Middle) (Last) (Jr., Sr., III)
(If different from above) When the events described in this affidavit took
place, I was known as
________________________________________________________________
(First) (Middle) (Last) (Jr., Sr., III)
(3) My date of birth is ____________________
(day/month/year)
(4) My Social Security number is ____________________
(5) My driver’s license or identification card state and number are
__________________________
(6) My current address is ________________________________________________
City ___________________________ State ________
Zip Code ________
(7) I have lived at this address since
____________________
(month/year)
(8) (If different from above) When the events described in this affidavit took
place, my address was
________________________________________________
City ___________________________ State ____________
Zip Code ______________
(9) I lived at the address in Item 8 from __________ until
(month/year)
_______________
(month/year)
(10) My daytime telephone number is
(____)____________________
My evening telephone number is
(____)____________________
How the Fraud Occurred
Circle all that apply for items 11 - 17:
(11) I did not authorize anyone to use my name or personal information to seek
the money, credit, loans, goods or services described in this report.
(12) I did not receive any benefit, money, goods or services as a result of the
events described in this report.
(13) My identification documents (for example, credit cards; birth certificate;
driver’s license; Social Security card; etc.) were ❑ stolen ❑ lost on or about
__________________.
(day/month/year)
(14) To the best of my knowledge and belief, the following person(s) used my
information (for example, my 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 my knowledge or
authorization:
____________________________________
Name (if known)
____________________________________
Address (if known)
____________________________________
Phone number(s) (if known)
_________________________________
_________________________________
Additional information (if known)
____________________________________
Name (if known)
____________________________________
Address (if known)
____________________________________
Phone number(s) (if known)
_________________________________
_________________________________
Additional information (if known)
(15) I do NOT know who used my information or identification documents to get
money, credit, loans, goods or services without my knowledge or authorization.
(16) Additional comments: (For example, description of the fraud, which
documents or information were used or how the identity thief gained access to
your information.)
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
(Attach additional pages as necessary.)
Victim’s Law Enforcement Actions
Circle One
(17) (I am) (am not) willing to assist in the prosecution of the person(s) who
committed this fraud.
Circle One
(18) (I am) (am not) authorizing the release of this information to law
enforcement for the purpose of assisting them in the investigation and
prosecution of the person(s) who committed this fraud.
Circle One
(19) (I have) (have not) reported the events described in this affidavit to the
police or other law enforcement agency.
The police (did) (did not) write a report. In the event you have contacted the
police or other law enforcement agency, please complete the following:
_____________________________
(Agency #1)
_________________________________
(Officer/Agency personnel taking report)
____________________________
(Date of report)
_________________________________
(Report number, if any)
_____________________________
_________________________________
(Phone number)
_________________________________
(email address, if any)
_____________________________
(Agency #2)
_________________________________
(Officer/Agency personnel taking report)
_____________________________
(Date of report)
_________________________________
(Report number, if any)
_____________________________
(Phone number)
_________________________________
(email address, if any)
Documentation Checklist
Please indicate the supporting documentation you are able to provide to the
companies you plan to notify. Attach copies (NOT originals) to the affidavit
before sending it to the companies.
(20) A copy of a valid government-issued photo-identification card (for example,
your driver’s license, state-issued ID card or your passport). If you are under
16 and don’t have a photo-ID, you may submit a copy of your birth certificate or
a copy of your official school records showing your enrollment and place of
residence.
(21) Proof of residency during the time the disputed bill occurred, the loan was
made or the other event took place (for example, a rental/lease agreement in
your name, a copy of a utility bill or a copy of an insurance bill).
(22) A copy of the report you filed with the police or sheriff’s department. If
you are unable to obtain a report or report number from the police, please
indicate that in Item 19. Some companies only need the report number, not a copy
of the report. You may want to check with each company.
Signature
I certify that, to the best of my knowledge and belief, all the information on
and attached to this affidavit is true, correct, and complete and made in good
faith.
I also understand that is affidavit 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 constitute a violation of 18 U.S.C. §1001
or other federal, state, or local criminal statutes, and may result in
imposition of a fine or imprisonment or both.
__________________________________
(signature)
__________________
(date signed)
______________________________________
(Notary)
[Check with each company. Creditors sometimes require notarization. If they do
not, please have one witness (non-relative) sign below that you completed and
signed this affidavit.]
Witness:
_______________________________________
(signature)
_______________________________________
(printed name)
____________
(date)
__________________________________
(telephone number)
It’s a daunting process to be sure and one that will take quite some time to
resolve, but it can be resolved. You can reclaim your identity! How do you
prevent it from happening again?
Next article: How to Avoid Becoming An Identity Theft Victim
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