"Identity Theft Notification and Affidavit" - Ohio

Identity Theft Notification and Affidavit is a legal document that was released by the Ohio Attorney General - a government authority operating within Ohio.

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Download "Identity Theft Notification and Affidavit" - Ohio

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Consumer Protection Section
Office 614-466-8831
IDENTITY THEFT NOTIFICATION AND AFFIDAVIT
Please Note:
Information you submit with your Notification and Affidavit is considered public
information and may be released as part of a public records request. Efforts will be made to safeguard
information you are providing as protected by law.
Document Checklist
When submitting this form, please include the following supporting documentation:
 A copy of a valid government-issued photo-identification card (ex. Driver’s License, state issued ID card,
or passport).
 A copy of the report you filed with the police or sheriff’s department.
Personal Information
Tell Us About Yourself: □ Mr. □ Mrs. □ Ms.
Active duty service or immediate family member? □ Yes
Full Legal Name: ____________________________________________________________________________
E-mail Address: _____________________________________________________________________________
Current Address: _____________________________________________________________________________
City: ______________________________________ State: _______________ Zip Code: __________________
Daytime Phone: (
) _______________________
Cell Phone: (
) ________________________
Previous Address: ___________________________________________ Dates: From __________To _________
City: ______________________________________ State: _______________ Zip Code: __________________
Previous Telephone Number: (
) _____________________ Date of Birth: _____________________________
Social Security Number (last four only): XXX – XX - ___ ___ ___ ___
Driver’s License or Identification Card state and number: _____________________________________________
ID Theft Affidavit
Page 1 of 3
Consumer Protection Section
Office 614-466-8831
IDENTITY THEFT NOTIFICATION AND AFFIDAVIT
Please Note:
Information you submit with your Notification and Affidavit is considered public
information and may be released as part of a public records request. Efforts will be made to safeguard
information you are providing as protected by law.
Document Checklist
When submitting this form, please include the following supporting documentation:
 A copy of a valid government-issued photo-identification card (ex. Driver’s License, state issued ID card,
or passport).
 A copy of the report you filed with the police or sheriff’s department.
Personal Information
Tell Us About Yourself: □ Mr. □ Mrs. □ Ms.
Active duty service or immediate family member? □ Yes
Full Legal Name: ____________________________________________________________________________
E-mail Address: _____________________________________________________________________________
Current Address: _____________________________________________________________________________
City: ______________________________________ State: _______________ Zip Code: __________________
Daytime Phone: (
) _______________________
Cell Phone: (
) ________________________
Previous Address: ___________________________________________ Dates: From __________To _________
City: ______________________________________ State: _______________ Zip Code: __________________
Previous Telephone Number: (
) _____________________ Date of Birth: _____________________________
Social Security Number (last four only): XXX – XX - ___ ___ ___ ___
Driver’s License or Identification Card state and number: _____________________________________________
ID Theft Affidavit
Page 1 of 3
Name: _________________________________
How the Fraud Occurred
Review and check all that apply:
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.
I did NOT receive any benefit, money, goods, or services as a result of the events described in this report.
I do NOT know who used my information or identification documents to get money, credit, loans, goods, or
services without my knowledge or authorization.
To the best of my knowledge and belief, the following person(s) used my information or identification
documents to commit identity theft:
Name (if known): _________________________________ Phone Number (if known): _____________________
Address (if known): ___________________________________________________________________________
Fraudulent Account Statement – Creditor(s)/Collection Agencies
List the entities you would like us to contact. Include copies of bills, invoices, correspondences, etc.
As a result of the events described in this Notification and Affidavit, the following account(s) was/were opened
in my name without my knowledge, permission, or authorization using my personal identification or identifying
documents:
Name of Creditor/Collector
Account Number
Disputed Amount
Review and check all of the following:
I expressly authorize the Ohio Attorney General’s Office to speak with the creditors, collectors, or any other
entity listed above regarding the accounts listed above for the sole purpose of resolving any issues related to
events described in the Identity Theft Notification and Affidavit.
I expressly authorize the creditors, collectors, or any other entity listed above to speak with the Ohio Attorney
General’s Office regarding the accounts listed above for the sole purpose of resolving any issues related to
events described in the Identity Theft Notification and Affidavit.
ID Theft Affidavit
Page 2 of 3
Name: _________________________________
Signature
YOUR SIGNATURE MUST BE NOTARIZED
By signing below, I acknowledge and understand that any information I submit to the Ohio Attorney
General’s Office is considered public information and may be released in a public records request. I
understand a copy of this form and all relevant documents related to my Notification and Affidavit will be
forwarded to the company/companies identified in my Notification and Affidavit. I understand that the
Ohio Attorney General cannot serve as my private attorney.
I declare under the penalty of perjury that the information in this Affidavit is true and correct to the best of
my knowledge.
SIGNATURE
Sworn to and subscribed in my presence this _________ day of _____________________, _________
in the City of ________________________, County of _____________________, State of Ohio.
NOTARY PUBLIC
My Commission Expires
Return to:
The Office of Ohio Attorney General
Consumer Protection Section - Identity Theft Unit
th
30 East Broad Street, 14
Floor
Columbus, Ohio 43215
ID Theft Affidavit
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