Id Theft Affidavit Page 2
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7ID THEFT AFFIDAVIT
Fraudulent Account Statement
This affidavit provided for:
Directions for completing this affidavit:
(Name and Mailing Address)
• Make copies of this completed affidavit and any
additional documents for your records prior to
sending them to PG&E.
• List only the PG&E account(s) you are disputing.
See the example below.
• If PG&E or a third party collection agency
sent you a statement, letter or notice about
the fraudulent account, attach a copy of that
document (NOT the original).
• A copy of the report you filed with the police or
sheriff’s department MUST be returned with
this completed affidavit.
Name
Phone Number
I declare (check all that apply):
n
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.
Creditor Name/
Account Number
Address where Utility Service
Date Service
Amount of
Address
was Provided by PG&E
Opened and Closed
**
Bill
Pacific Gas and
Opened date:
Electric Company
P.O. Box 8329
Closed date:
Stockton, CA 95210
Opened date:
Closed date:
n
During the time of the accounts described above, I had the following account open with PG&E, which was opened
with my authorization:
Billing name ___________________________________________________________________________________
Billing address _________________________________________________________________________________
Account number _______________________________________________________________________________
Proof of residency documents must be from two (2) separate sources that cover the entire time period of the
**
disputed charges. See page 6, Category III, for Acceptable Proof of Residency.
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