Id Theft Affidavit (Page 4 of 7) in pdf

Id Theft Affidavit Page 4

ID THEFT AFFIDAVIT

How the Fraud Occurred

11.

I did not authorize anyone to use my name or personal information to obtain the gas and/or electric service

described in this report.

12.

I did not reside at the address where the service was provided.

13.

I did not receive or benefit from the gas and/or electric service described in this report.

14.

My identification documents (for example: credit cards, birth certificate, driver’s license, social security card,

stolen or

lost on or about _____________________________________

etc.) were:

(month/day/year)

15.

To the best of my knowledge and belief, the following person(s) used my information (name, social security

number, etc.) or identification documents to obtain gas and/or electric service without my knowledge or

authorization:

Name (if known)

Address (if known)

Phone Number(s) (if known)

Additional Information (if known)

16.

I do NOT know who used my information or identification documents to obtain gas and/or electric service

without my knowledge or authorization.

17.

Additional comments: For example: descriptions of fraud, which documents or information were used, or how

the identity thief gained access to your information. (Attach additional pages as necessary.)

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Id Theft Affidavit Page 4