"Identity Theft Victim's Complaint and Affidavit Form" - California

Identity Theft Victim's Complaint and Affidavit Form is a legal document that was released by the California Department of Justice - a government authority operating within California.

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Download "Identity Theft Victim's Complaint and Affidavit Form" - California

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Average time to complete: 10 minutes
Identity Theft Victim’s Complaint and Affidavit
A voluntary form for filing a report with law enforcement, and disputes with credit reporting agencies and creditors about
identity theft-related problems. Visit identitytheft.gov to use a secure online version that you can print for your records.
Before completing this form:
1. Place a fraud alert on your credit reports, and review the reports for signs of fraud.
2. Close the accounts that you know, or believe, have been tampered with or opened fraudulently.
About You (the victim)
Now
Leave (3)
(1)
My full legal name: ________________________________________________
blank until
you provide
First
Middle
Last
Suffix
this form to
(2)
My date of birth: __________________
someone with
mm/dd/yyyy
a legitimate
(3)
My Social Security number: ________-______-__________
business need,
like when you
(4)
My driver’s license: _________
___________________
are filing your
State
Number
report at the
police station
(5)
My current street address:
or sending
the form
____________________________________________________________________________
to a credit
Number & Street Name
Apartment, Suite, etc.
reporting
_______________________________________________________________
agency to
correct your
City
State
Zip Code
Country
credit report.
(6)
I have lived at this address since ____________________
mm/yyyy
(7)
My daytime phone: (____)___________________
My evening phone: (____)___________________
My email: ______________________________________
At the Time of the Fraud
Skip (8) - (10)
(8)
My full legal name was: ____________________________________________
if your
information
First
Middle
Last
Suffix
has not
(9)
My address was: _________________________________________________
changed since
Number & Street Name
Apartment, Suite, etc.
the fraud.
_______________________________________________________________
City
State
Zip Code
Country
(10)
My daytime phone: (____)_________________ My evening phone: (____)_________________
My email: _____________________________________
The Paperwork Reduction Act requires the FTC to display a valid control number (in this case, OMB control #3084-0047)
before we can collect – or sponsor the collection of – your information, or require you to provide it.
Average time to complete: 10 minutes
Identity Theft Victim’s Complaint and Affidavit
A voluntary form for filing a report with law enforcement, and disputes with credit reporting agencies and creditors about
identity theft-related problems. Visit identitytheft.gov to use a secure online version that you can print for your records.
Before completing this form:
1. Place a fraud alert on your credit reports, and review the reports for signs of fraud.
2. Close the accounts that you know, or believe, have been tampered with or opened fraudulently.
About You (the victim)
Now
Leave (3)
(1)
My full legal name: ________________________________________________
blank until
you provide
First
Middle
Last
Suffix
this form to
(2)
My date of birth: __________________
someone with
mm/dd/yyyy
a legitimate
(3)
My Social Security number: ________-______-__________
business need,
like when you
(4)
My driver’s license: _________
___________________
are filing your
State
Number
report at the
police station
(5)
My current street address:
or sending
the form
____________________________________________________________________________
to a credit
Number & Street Name
Apartment, Suite, etc.
reporting
_______________________________________________________________
agency to
correct your
City
State
Zip Code
Country
credit report.
(6)
I have lived at this address since ____________________
mm/yyyy
(7)
My daytime phone: (____)___________________
My evening phone: (____)___________________
My email: ______________________________________
At the Time of the Fraud
Skip (8) - (10)
(8)
My full legal name was: ____________________________________________
if your
information
First
Middle
Last
Suffix
has not
(9)
My address was: _________________________________________________
changed since
Number & Street Name
Apartment, Suite, etc.
the fraud.
_______________________________________________________________
City
State
Zip Code
Country
(10)
My daytime phone: (____)_________________ My evening phone: (____)_________________
My email: _____________________________________
The Paperwork Reduction Act requires the FTC to display a valid control number (in this case, OMB control #3084-0047)
before we can collect – or sponsor the collection of – your information, or require you to provide it.
Victim’s Name _______________________________ Phone number (____)_________________ Page 2
About You (the victim) (Continued)
Declarations
(11)
I
did OR
did not
authorize anyone to use my name or personal information to
obtain money, credit, loans, goods, or services — or for any
other purpose — as described in this report.
(12)
I
did OR
did not
receive any money, goods, services, or other benefit as a
result of the events described in this report.
(13)
I
am OR
am not
willing to work with law enforcement if charges are brought
against the person(s) who committed the fraud.
About the Fraud
(14):
(14)
I believe the following person used my information or identification
Enter what
documents to open new accounts, use my existing accounts, or commit other
you know
about anyone
fraud.
you believe
was involved
Name: ___________________________________________________
(even if you
First
Middle
Last
Suffix
don’t have
complete
Address: __________________________________________________
information).
Number & Street Name
Apartment, Suite, etc.
__________________________________________________________
City
State
Zip Code
Country
Phone Numbers: (____)_______________ (____)________________
Additional information about this person: _____________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Victim’s Name _______________________________ Phone number (____)_________________ Page 3
(15)
Additional information about the crime (for example, how the identity thief
(14) and (15):
gained access to your information or which documents or information were
Attach
used):
additional
sheets as
________________________________________________________________
needed.
________________________________________________________________
________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Documentation
(16): Reminder:
(16)
I can verify my identity with these documents:
Attach copies
of your identity
A valid government-issued photo identification card (for example, my driver’s
documents
license, state-issued ID card, or my passport).
when sending
If you are under 16 and don’t have a photo-ID, a copy of your birth certificate or
this form to
a copy of your official school record showing your enrollment and legal address is
creditors
and credit
acceptable.
reporting
agencies.
Proof of residency during the time the disputed charges occurred, the loan
was made, or the other event took place (for example, a copy of a rental/lease
agreement in my name, a utility bill, or an insurance bill).
About the Information or Accounts
(17)
The following personal information (like my name, address, Social Security number, or date of
birth) in my credit report is inaccurate as a result of this identity theft:
(A) __________________________________________________________________________
(B) __________________________________________________________________________
(C) __________________________________________________________________________
(18)
Credit inquiries from these companies appear on my credit report as a result of this identity
theft:
Company Name: _______________________________________________________________
Company Name: _______________________________________________________________
Company Name: _______________________________________________________________
Victim’s Name _______________________________ Phone number (____)_________________ Page 4
(19)
Below are details about the different frauds committed using my personal information.
(19):
___________________________________________________________________
If there were
Name of Institution
Contact Person
Phone
Extension
more than three
frauds, copy this
___________________________________________________________________
page blank, and
Account Number
Routing Number
Affected Check Number(s)
attach as many
additional copies
Account Type:
Credit
Bank
Phone/Utilities
Loan
as necessary.
Government Benefits
Internet or Email
Other
Enter any
Select ONE:
applicable
information that
This account was opened fraudulently.
you have, even if
This was an existing account that someone tampered with.
it is incomplete
___________________________________________________________________
or an estimate.
Date Opened or Misused (mm/yyyy)
Date Discovered (mm/yyyy)
Total Amount Obtained ($)
If the thief
committed two
types of fraud at
___________________________________________________________________
one company,
Name of Institution
Contact Person
Phone
Extension
list the company
___________________________________________________________________
twice, giving
Account Number
Routing Number
Affected Check Number(s)
the information
about the two
Account Type:
Credit
Bank
Phone/Utilities
Loan
frauds separately.
Government Benefits
Internet or Email
Other
Contact Person:
Someone you
Select ONE:
dealt with, whom
This account was opened fraudulently.
an investigator
This was an existing account that someone tampered with.
can call about this
fraud.
___________________________________________________________________
Date Opened or Misused (mm/yyyy)
Date Discovered (mm/yyyy)
Total Amount Obtained ($)
Account Number:
The number of
the credit or
___________________________________________________________________
debit card, bank
Name of Institution
Contact Person
Phone
Extension
account, loan, or
___________________________________________________________________
other account
that was misused.
Account Number
Routing Number
Affected Check Number(s)
Dates: Indicate
Account Type:
Credit
Bank
Phone/Utilities
Loan
when the thief
Government Benefits
Internet or Email
Other
began to misuse
your information
Select ONE:
and when you
This account was opened fraudulently.
discovered the
problem.
This was an existing account that someone tampered with.
___________________________________________________________________
Amount Obtained:
For instance,
Date Opened or Misused (mm/yyyy)
Date Discovered (mm/yyyy)
Total Amount Obtained ($)
the total amount
purchased with
the card or
withdrawn from
the account.
Victim’s Name _______________________________ Phone number (____)_________________ Page 5
Your Law Enforcement Report
(20):
(20)
One way to get a credit reporting agency to quickly block identity theft-
Check “I have
related information from appearing on your credit report is to submit a
not...” if you have
detailed law enforcement report (“Identity Theft Report”). You can obtain
not yet filed a
report with law
an Identity Theft Report by taking this form to your local law enforcement
enforcement or
office, along with your supporting documentation. Ask an officer to witness
you have chosen
your signature and complete the rest of the information in this section. It’s
not to. Check “I
important to get your report number, whether or not you are able to file in
was unable...” if
person or get a copy of the official law enforcement report. Attach a copy of
you tried to file
a report but law
any confirmation letter or official law enforcement report you receive when
enforcement
sending this form to credit reporting agencies.
refused to take it.
Select ONE:
Automated report:
I have not filed a law enforcement report.
A law
enforcement
I was unable to file any law enforcement report.
report filed
I filed an automated report with the law enforcement agency listed
through an
below.
automated
I filed my report in person with the law enforcement
system, for
officer and agency listed below.
example, by
telephone, mail,
or the Internet,
instead of a
____________________________________________________________________
face-to-face
Law Enforcement Department
State
interview with a
law enforcement
officer.
____________________________
_____________________
Report Number
Filing Date (mm/dd/yyyy)
____________________________________________________________________
Officer’s Name (please print)
Officer’s Signature
____________________________
(____)_______________
Badge Number
Phone Number
Did the victim receive a copy of the report from the law enforcement officer?
Yes OR
No
Victim’s FTC complaint number (if available): ________________________
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