If victim of ID Theft
Instructions for Completing the ID Theft
Affidavit (6 pages)
To make certain that you do not
become responsible for any debts incurred by an identity thief, you must prove
to each of the companies where accounts were opened or used in your name that
you didn’t create the debt. A group of
credit grantors, consumer advocates, and attorneys at the Federal Trade
Commission (FTC) developed an ID Theft Affidavit to make it easier for fraud
victims to report information.
While many companies accept
this affidavit, others require that you submit more or different forms. Before
you send the affidavit, contact each company to find out if they accept
it. It will be necessary to provide the
information in this affidavit anywhere a new account was opened in your
name. The information will enable the companies to investigate the fraud and
decide the outcome of your claim. If someone made unauthorized charges to an existing account,
call the company for instructions.
This affidavit has two parts:
• Part One — the ID Theft Affidavit — is where you report general
information about yourself and the theft.
• Part Two — the Fraudulent Account Statement — is where you describe the
fraudulent account(s) opened in your name. Use a separate Fraudulent Account
Statement for each company you need to write to. When you send the affidavit to the companies,
attach copies (NOT originals) of any supporting documents (for example,
driver’s license or police report).
Before submitting your
affidavit, review the disputed account(s) with family members or friends who
may have information about the account(s) or access to them. Complete this affidavit as soon as
possible. Many creditors ask that you
send it within two weeks. Delays on your part could slow the investigation. Be as accurate and complete as possible. You
may choose not to provide some of the information requested. However, incorrect
or incomplete information will slow the process of investigating your claim and
absolving the debt. Print clearly. When
you have finished completing the affidavit, mail a copy to each creditor, bank,
or company that provided the thief with the unauthorized credit, goods, or
services you describe.
Attach a copy of the
Fraudulent Account Statement with information only on accounts opened at the
institution to which you are sending the packet, as well as any other
supporting documentation you are able to provide. Send the appropriate documents to each
company by certified mail, return receipt requested, so you can prove that it
was received. The companies will review
your claim and send you a written response telling you the outcome of their
investigation. Keep a copy of “everything you submit”. If you are unable to
complete the affidavit, a legal guardian or someone with power of attorney may
complete it for you. Except as noted,
the information you provide will be used only by the company to process your
affidavit, investigate the events you report, and help stop further fraud. If this affidavit is requested in a lawsuit,
the company might have to provide it to the requesting party. Completing this affidavit does not guarantee that
the identity thief will be apprehended, prosecuted or that the debt will be
cleared.
Report the fraud to the
following organizations:
1. Any one of the nationwide consumer reporting companies to place
a fraud alert on your credit report. Fraud alerts can help prevent an identity
thief from opening any more accounts in your name. The company you call is
required to contact the other two, which will place an alert on their versions
of your report, to the following:
• Equifax: 1-800-525-6285; www.equifax.com
• Experian: 1-888-EXPERIAN (397-3742); www.experian.com
• TransUnion: 1-800-680-7289; www.transunion.com
In addition to placing the
fraud alert, the three consumer reporting companies will send you free copies
of your credit reports, and, if you ask, they will display only the last four
digits of your Social Security number on your credit reports.
2. The security or fraud
department of each company where you know, or believe, accounts have been
tampered with or opened fraudulently. Close the accounts. Follow up in writing,
and include copies (NOT originals) of supporting documents. It’s important to notify credit card companies and banks in
writing. Send
your letters by certified mail, return receipt requested,
so you can document what the company received and when. Keep a file of your correspondence and
enclosures. When you open new accounts, use new Personal Identification Numbers
(PIN’s)
and passwords. Avoid using easily
available information like your mother’s maiden name, your birth date, the last
four digits of your Social Security number or your phone number, or a series of
consecutive numbers.
3. Your local police or the
police in the community where the identity theft took place to file a report.
Get a copy of the police report or, at the very least, the number of the
report. It can help you deal with creditors who need proof of the crime. If the
police are reluctant to take your report, ask to file a “Miscellaneous
Incidents” report, or try another jurisdiction, like your state police. You
also can check with your state Attorney General’s office to find out if state
law requires the police to take reports for identity theft. Check the Blue
Pages of your telephone directory for the phone number or check www.naag.org for a list of state
Attorneys General.
4. The Federal Trade
Commission. By sharing your identity
theft complaint with the FTC, you will provide important information that can
help law enforcement officials across the nation track down identity thieves
and stop them. The FTC also can refer victims’ complaints to other government
agencies and companies for further action, as well as investigate companies for
violations of laws that the FTC enforces. You can file a complaint online at
the following: www.consumer.gov/idtheft. If you don’t have
Internet access, call the FTC’s Identity Theft Hotline, toll-free: 1-877-IDTHEFT (438-4338); TTY:
1-866-653-4261; or write:
Identity Theft Clearinghouse
Federal Trade Commission
NW,
Supply
the following information:
(1) My full legal name is ________________________________________________________________
(First) (Middle) (Last) (Jr., Sr., III)
(2) (If different from above) When the events described in this
affidavit took place, I was known as __________________________________________________________________________________
(First) (Middle) (Last) (Jr., Sr., III)
(3) My date of birth is ____________________ (day/month/year)
(4) My Social Security number
is________-___________-_____________
(5) My driver’s license or identification card state and number
are__________________________
(6) My current address is
_________________________________________________________________
(7) I have lived at this address since ____________________(month/year)
(8) (If different from above) When the events described in this
affidavit took place, my address was _________________________________________________________________________________
(9) I lived at the address in Item (8) from ____________(Mo./Year) until __________(Mo./Year)
(10) My daytime telephone number is
(________)____________________________
My evening telephone number is
(_________)_______________________________
ID Theft Affidavit
Name ____________________________________
Phone number (______)_______-___________
Name ____________________________________
Phone number (______)_______-___________
How the Fraud Occurred-Check all that apply for items 11 - 17:
(11) 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.
(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: credit cards, birth certificate, driver’s license,
Social Security card, etc.) were stolen, lost on or about
__________________(day/month/year)
(14) 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, mother’s maiden name, etc.) or identification documents to get money,
credit, loans, goods or services without my knowledge or authorization:
__________________________________________________________
Name (if known) Name (if
known)
__________________________________________________________
Address (if known) Address (if
known)
__________________________________________________________
Phone number(s) (if known)
Phone number(s) (if known)
__________________________________________________________
Additional information (if
known) Additional information (if known)
__________________________________________________________
(15) I do NOT know who used my
information or identification documents to get money, credit, loans, goods or
services without my knowledge or authorization.
(16) Additional comments: (For example, description of the fraud, which
documents or information was used or how the identity thief gained access to
your information.)
__________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Attach additional pages as necessary.)
Name __________________________________
Phone number
Victim’s Law Enforcement Actions
(17) (check one) ____I am ____Am not willing, to assist in the
prosecution of the person(s) who
committed this fraud.
(18) (check one) ____I am
____Am not, authorizing the release of this information to law enforcement for
the purpose of assisting them in the investigation and prosecution of the
person(s) who committed this fraud.
(19) (check all that apply)
____I have ____I have not reported the events described in this affidavit to
the police or other law enforcement agency.
The police ____did ____did not write a
report. In the event you have contacted the
police or other law enforcement agency, please
complete the
following:
(Agency #1) (Officer/Agency personnel taking report)
____________________________ _________________________________
(Date of report) (Report number, if any)
______/______/________ ________________________________________
(Phone number) (email address, if any)
_____________________________ _________________________________
(Agency #2) (Officer/Agency personnel name(s) taking report)
_____________________________ _________________________________
(Date of report) (Report number, if any)
______/______/________ ________________________________________
(Phone number) (email
address, if any)
_____________________________ _________________________________
Documentation Checklist
Please indicate the supporting
documentation you are able to provide to the companies you plan to notify. Attach copies (NOT originals) to the
affidavit before sending it to the companies.
(20) A copy of a valid
government-issued photo-identification card (for example, your driver’s
license, state-issued ID card
or your passport). If you are under 16 and don’t have a photo-ID, you may
submit a copy of your birth certificate or a copy of your official school
records showing your enrollment and place of residence.
(21) Proof of residency during
the time the disputed bill occurred, the loan was made or the other event took
place (for example, a rental/lease agreement in your name, a copy of a utility
bill or a copy of an insurance bill).
(22) A copy of the report you
filed with the police or sheriff’s department. If you are unable to
obtain a report or report
number from the police, please indicate that in Item 19. Some
companies only need the report
number, not a copy of the report. You may want to check with each company.
Signature Page:
I certify that, to the best of
my knowledge and belief, all the information on and attached to this
affidavit is true, correct,
and complete and made in good faith. I also understand that is affidavit or the
information it contains may be made available to federal, state, and/or local
law enforcement agencies for such action within their jurisdiction as they deem
appropriate. I understand that knowingly making any false or fraudulent
statement or representation to the government may constitute a violation of 18
U.S.C. §1001 or other federal, state, or local criminal statutes, and may
result in imposition of a fine or imprisonment or both.
______________________________________________
__________________________________
(victim signature)
(date signed)
______________________________________
(Notary)
[Check with each
company. Creditors sometimes require notarization. If they do not, please have
one witness (non-relative) sign below that you completed and signed this
affidavit.]
Witness:
__________________________________________
_____________________________________
(witness signature)
(printed name)
_______________________
__________________________________
(date)
(telephone number)
DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER GOVERNMENT AGENCY
DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER GOVERNMENT AGENCY
I declare (list all that
apply):
As a result of the event(s) described
in the ID Theft Affidavit, the following account(s) was/were
opened at your company in my
name without my knowledge, permission or authorization using
my personal information or
identifying documents:
Completing this
Statement
• Make as many copies of this
page as you need. Complete a separate
page for each
company you’re
notifying and only send it to that company. Include
a copy of your
signed affidavit.
• List only the account(s)
you’re disputing with the company receiving this form. See the
example below.
• If a collection agency sent you a statement, letter or notice
about the fraudulent account,
attach a copy of that document
(NOT the original).
Fraudulent Account Statement
Creditor Name/Address
(the company that opened the account or
provided the goods or services)
Account Number_______________________
Type of unauthorized credit/goods/services
provided by creditor
(if
known)_________________________________________________________
Date issued or opened (if
known)__________________________________
Amount/Value provided (the amount charged for the
goods/services) $__________________
During the time of the accounts described above, I had the
following account open with your company:
Billing name ___________________________________________________________________
Billing
address__________________________________________________________________
Account number
_______________________________________________________________
Example:
ABC National Bank
1515 Anywhere Lane
01234567-89 auto loan 01/05/2002 $25,500.00
Contact Name
__________________________________ Phone number _______________________
DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER GOVERNMENT AGENCY