Id Theft Affidavit (Page 3 of 7) in pdf

Id Theft Affidavit Page 3

ID THEFT AFFIDAVIT

Victim 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 _________________________________________________.

4. My social security number is ________________________________________.

5. My driver’s license or state identification card number is ______________________________. Issuing state_________

6. My current address is________________________________________________________________________________

__________________________________________________________________________________________________

City/State/Zip Code

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:

__________________________________________________________________________________________________

City/State/Zip Code

9. I lived at the address from ____________________________________ until ___________________________________

Month/Year

10. My daytime telephone number is (______ )_____________________________

My evening telephone number is (______ )_____________________________

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Id Theft Affidavit Page 3