"Identity Theft/Criminal Impersonation Affidavit" - Nebraska

Identity Theft/Criminal Impersonation Affidavit is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

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Download "Identity Theft/Criminal Impersonation Affidavit" - Nebraska

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IDENTITY THEFT / CRIMINAL IMPERSONATION AFFIDAVIT
The Nebraska State Statute which defines this crime is 28-638 Criminal Impersonation. In order
to violate this statute a person must use personal identification documents or personal identifying
information. This does not include the use of a credit card or credit accounts actually issued to
the victim to make a purchase.
If you feel that you are the victim of a crime under Nebraska State Statute 28-638, please
completely fill out this form and send it to:
Nebraska Department of Motor Vehicles
Attention: Fraud Unit
PO Box 94789
Lincoln, NE 68509-4789
Personal Information
1) My full legal name is ________________________________________________________________
(Last)
(First)
(Middle)
(Jr, Sr, III)
2) My date of birth is ___________________________________________________________________
(Month / Day / Year)
3) My current address is ________________________________________________________________
(Street number and name)
______________________________________________________________________________________
(City)
(State)
(Zip Code)
4) (If different than #3) When the events described in this affidavit took place my address was
______________________________________________________________________________________
(Street number and name)
______________________________________________________________________________________
(City)
(State)
(Zip Code)
5) I have lived at my current address since ________________________________________________
(Month / Day / Year)
6) If you lived at this address for less than one year, what was your previous address
______________________________________________________________________________________
(Street number and name)
______________________________________________________________________________________
(City)
(State)
(Zip Code)
7) My Social Security Number is _________________________________________________________
8) My Driver’s License or Identification is _________________________________________________
(State)
(Number)
9) My daytime telephone number is
(____) ____________________________________________
10) My evening telephone number is
(____) ____________________________________________
IDENTITY THEFT / CRIMINAL IMPERSONATION AFFIDAVIT
The Nebraska State Statute which defines this crime is 28-638 Criminal Impersonation. In order
to violate this statute a person must use personal identification documents or personal identifying
information. This does not include the use of a credit card or credit accounts actually issued to
the victim to make a purchase.
If you feel that you are the victim of a crime under Nebraska State Statute 28-638, please
completely fill out this form and send it to:
Nebraska Department of Motor Vehicles
Attention: Fraud Unit
PO Box 94789
Lincoln, NE 68509-4789
Personal Information
1) My full legal name is ________________________________________________________________
(Last)
(First)
(Middle)
(Jr, Sr, III)
2) My date of birth is ___________________________________________________________________
(Month / Day / Year)
3) My current address is ________________________________________________________________
(Street number and name)
______________________________________________________________________________________
(City)
(State)
(Zip Code)
4) (If different than #3) When the events described in this affidavit took place my address was
______________________________________________________________________________________
(Street number and name)
______________________________________________________________________________________
(City)
(State)
(Zip Code)
5) I have lived at my current address since ________________________________________________
(Month / Day / Year)
6) If you lived at this address for less than one year, what was your previous address
______________________________________________________________________________________
(Street number and name)
______________________________________________________________________________________
(City)
(State)
(Zip Code)
7) My Social Security Number is _________________________________________________________
8) My Driver’s License or Identification is _________________________________________________
(State)
(Number)
9) My daytime telephone number is
(____) ____________________________________________
10) My evening telephone number is
(____) ____________________________________________
IDENTITY THEFT / CRIMINAL IMPERSONATION AFFIDAVIT
How the Fraud Occurred
Check all that apply for items 11-16
11)
I did not authorize anyone to use my name or personal information.
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: Birth Certificate, Driver’s License, Social
Security Card, etc.) were:
Stolen
Lost
on or about ____________________________________________________________________
(Month / Day / Year
14)
I do NOT know who used my information or identification documents without my
knowledge or authorization.
15)
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, etc.) or identification documents to get money, credit accounts, loans, goods or
services without my knowledge or authorization.
_____________________________________
____________________________________
Name (if known)
Name (if known)
_____________________________________
____________________________________
Address (if known)
Address (if known)
_____________________________________
____________________________________
Phone numbers (if known)
Phone numbers (if known)
_____________________________________
____________________________________
Additional information
Additional information
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.)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
(Use additional pages as necessary)
IDENTITY THEFT / CRIMINAL IMPERSONATION AFFIDAVIT
I, __________________________________________________ declare that everything in this report is
(Print name)
true and accurate to the best of my knowledge. I also understand that to knowingly submit false
information to a law enforcement officer can result in my prosecution for a criminal offense.
__________________________________________________
Signature
__________________________________________________
Date
__________________________________________________
Witness
__________________________________________________
Date
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