"Application for Identity Theft Passport" - Delaware

Application for Identity Theft Passport is a legal document that was released by the Delaware Department of Justice - a government authority operating within Delaware.

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Download "Application for Identity Theft Passport" - Delaware

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DEPARTMENT OF JUSTICE
820 NORTH FRENCH STREET
MATTHEW P. DENN
PHONE (800) 220-5424
WILMINGTON, DE 19801
ATTORNEY GENERAL
FAX (302) 577-6499
APPLICATION FOR IDENTITY THEFT PASSPORT
Please type or print legibly.
Name ______________________________________________________________________________
Last
First
Middle
Prior Name __________________________________________________________________________
Last
First
Middle
Mailing Address _____________________________________________________________________
Street or PO Box
City
State
Zip code
Other Address _______________________________________________________________________
Street or PO Box
City
State
Zip code
Home Phone ____________________________ Work Phone _________________________________
Date of Birth ____/____/____ Place of Birth _______________________________________________
City
State
County
Gender Male___ Female ___ Drivers License _____________________________________________
State
Number
CRIME INFORMATION
Date you discovered the theft __________________________________________________________
County and State where theft occurred __________________________________________________
Law enforcement agency taking police report ____________________________________________
Police report number _____________________ Date of police report __________________________
Has the person who stole your information been identified? YES ___ NO ___
If yes, suspect’s name ________________________________________________________________
Has an arrest been made? YES ___ NO ___ I DON’T KNOW ___
(Please continue on page 2)
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DEPARTMENT OF JUSTICE
820 NORTH FRENCH STREET
MATTHEW P. DENN
PHONE (800) 220-5424
WILMINGTON, DE 19801
ATTORNEY GENERAL
FAX (302) 577-6499
APPLICATION FOR IDENTITY THEFT PASSPORT
Please type or print legibly.
Name ______________________________________________________________________________
Last
First
Middle
Prior Name __________________________________________________________________________
Last
First
Middle
Mailing Address _____________________________________________________________________
Street or PO Box
City
State
Zip code
Other Address _______________________________________________________________________
Street or PO Box
City
State
Zip code
Home Phone ____________________________ Work Phone _________________________________
Date of Birth ____/____/____ Place of Birth _______________________________________________
City
State
County
Gender Male___ Female ___ Drivers License _____________________________________________
State
Number
CRIME INFORMATION
Date you discovered the theft __________________________________________________________
County and State where theft occurred __________________________________________________
Law enforcement agency taking police report ____________________________________________
Police report number _____________________ Date of police report __________________________
Has the person who stole your information been identified? YES ___ NO ___
If yes, suspect’s name ________________________________________________________________
Has an arrest been made? YES ___ NO ___ I DON’T KNOW ___
(Please continue on page 2)
1
Provide a brief description of the theft including what was stolen (e.g. credit card, SSN, etc.) and
the numbers of any accounts that have been affected.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please provide any supporting documentation that may substantiate a claim of identity theft.
Supporting documents include but are not limited to a completed identity theft affidavit, receipts
or bills from creditors showing unauthorized use, utility accounts created using your name
without permission, fraudulent checks, bank statements or any other evidence that your identity
has been used without your consent.
CERTIFICATION
I hereby certify with my signature below that the information provided on this form is true and accurate to
the best of my knowledge and that I have filed a police report of this incident. I understand if I knowingly
provide false information, I may be subject to prosecution.
____________________________________________________
Applicant Signature
Date: _____________________
Please mail or fax this form to:
Department of Justice – ID Theft Passport Program
Consumer Protection Unit
Carvel State Office Building
820 N. French St., Fifth Floor
Wilmington, DE 19801
Fax: (302) 577-6499
For additional information call:
(302) 577-8600 in New Castle County or
(800) 220-5424 in Sussex and Kent Counties
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