Identity Theft Victim'S Complaint And Affidavit (Page 6 of 6) in pdf

Identity Theft Victim'S Complaint And Affidavit Page 6

Victim’s Name _______________________________ Phone number (____)_________________ Page 6

Signature

As applicable, sign and date IN THE PRESENCE OF a law enforcement officer, a notary, or

a witness.

(21)

I certify that, to the best of my knowledge and belief, all of the information on and attached to

this complaint is true, correct, and complete and made in good faith. I understand that this

complaint 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 violate federal, state, or local criminal statutes, and may result in a fine,

imprisonment, or both.

_______________________________________

_________________________________________

Signature

Date Signed (mm/dd/yyyy)

Your Affidavit

(22)

If you do not choose to file a report with law enforcement, you may use this form as an Identity

Theft Affidavit to prove to each of the companies where the thief misused your information that

you are not responsible for the fraud. While many companies accept this affidavit, others require

that you submit different forms. Check with each company to see if it accepts this form. You

should also check to see if it requires notarization. If so, sign in the presence of a notary. If it

does not, please have one witness (non-relative) sign that you completed and signed this Affidavit.

If someone has used your Social Security number (SSN) to get a tax refund or a job, or you

suspect your SSN has been stolen, alert the IRS using Form 14039 at

_______________________________________

Notary

Witness:

_______________________________________

_________________________________________

Signature

Printed Name

_______________________________________

_________________________________________

Date

Telephone Number

Identity Theft Victim'S Complaint And Affidavit Page 6