"Identity Theft Consent Form" - Arkansas

Identity Theft Consent Form is a legal document that was released by the Arkansas Department of Public Safety - a government authority operating within Arkansas.

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Download "Identity Theft Consent Form" - Arkansas

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IDENTITY THEFT FILE CONSENT DOCUMENT
By signing this document, I hereby provide the ____________________________
permission to enter my personal data into the Federal Bureau of Investigation’s (FBI’s)
Identity Theft File. This information may include, but is not limited to, physical
descriptors and identifying information including my name, date of birth, place of birth,
Social Security number, the type of identity theft, and a password provided to me for
future identification verification purposes. I am also providing permission to enter my
photograph and fingerprints into this file when that capability becomes available.
I understand that this information is being submitted as part of a criminal investigation of
a crime of which I was a victim and will be available to entities having access to the
FBI’s National Crime Information Center (NCIC) files for any authorized purpose. I am
providing this data voluntarily as a means to document my claim of identify theft and to
obtain a unique password to be used for future identity verification purposes.
I understand that the FBI intends to remove this information from the NCIC active file no
later than five years from the date of entry. I also understand that I may at any time
submit a written request to the entering agency to have this information removed from the
active file at an earlier date. I further understand that information removed from the
active file will not thereafter be accessible via NCIC terminals, but it will be retained by
the FBI as a record of the NCIC entry until such time as its deletion may be authorized by
the National Archives and Records Administration.
I understand that this is a legally binding document reflecting my intent to have personal
data entered into the FBI's Identity Theft File. I declare under penalty of perjury that the
foregoing is true and correct. (See Title 28, United States Code [U.S.C.], Section 1746.)
____________________________________
__________________
SIGNATURE
DATE
____________________________________
PRINTED NAME
The Privacy Act of 1974 (5 U.S.C. § 552a) requires that local, state, or federal agencies
inform individuals whose Social Security number is being requested whether such
disclosure is mandatory or voluntary, the basis of authority for such solicitation, and the
uses which will be made of it. Accordingly, disclosure of your Social Security number is
voluntary; it is being requested pursuant to 28 U.S.C. § 534 for the purposes described
above. The Social Security number will be used as an identification tool; consequently,
failure to provide the number may result in a reduced ability to make such identifications
or provide future identity verifications.
IDENTITY THEFT FILE CONSENT DOCUMENT
By signing this document, I hereby provide the ____________________________
permission to enter my personal data into the Federal Bureau of Investigation’s (FBI’s)
Identity Theft File. This information may include, but is not limited to, physical
descriptors and identifying information including my name, date of birth, place of birth,
Social Security number, the type of identity theft, and a password provided to me for
future identification verification purposes. I am also providing permission to enter my
photograph and fingerprints into this file when that capability becomes available.
I understand that this information is being submitted as part of a criminal investigation of
a crime of which I was a victim and will be available to entities having access to the
FBI’s National Crime Information Center (NCIC) files for any authorized purpose. I am
providing this data voluntarily as a means to document my claim of identify theft and to
obtain a unique password to be used for future identity verification purposes.
I understand that the FBI intends to remove this information from the NCIC active file no
later than five years from the date of entry. I also understand that I may at any time
submit a written request to the entering agency to have this information removed from the
active file at an earlier date. I further understand that information removed from the
active file will not thereafter be accessible via NCIC terminals, but it will be retained by
the FBI as a record of the NCIC entry until such time as its deletion may be authorized by
the National Archives and Records Administration.
I understand that this is a legally binding document reflecting my intent to have personal
data entered into the FBI's Identity Theft File. I declare under penalty of perjury that the
foregoing is true and correct. (See Title 28, United States Code [U.S.C.], Section 1746.)
____________________________________
__________________
SIGNATURE
DATE
____________________________________
PRINTED NAME
The Privacy Act of 1974 (5 U.S.C. § 552a) requires that local, state, or federal agencies
inform individuals whose Social Security number is being requested whether such
disclosure is mandatory or voluntary, the basis of authority for such solicitation, and the
uses which will be made of it. Accordingly, disclosure of your Social Security number is
voluntary; it is being requested pursuant to 28 U.S.C. § 534 for the purposes described
above. The Social Security number will be used as an identification tool; consequently,
failure to provide the number may result in a reduced ability to make such identifications
or provide future identity verifications.