Id Theft Affidavit (Page 5 of 7) in pdf

Id Theft Affidavit Page 5

ID THEFT AFFIDAVIT

Victim’s Law Enforcement Actions

Check one:

18.

I am

I am not willing to assist in the prosecution of the person (or persons) who committed this fraud.

19.

I am

I 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.

20.

I have

I have not reported the events described in this affidavit to the police or other law enforcement agency.

If you checked “I have” above

: The police

did

did not write a report.

(check one)

21. You remain responsible for this/these bill(s) while our investigation is being conducted.

22. You will be notified with our results at the conclusion of our investigation.

Documentation Checklist

Please attach copies (NOT originals) of the documents listed below to this affidavit. Please see page 6 for a list of

acceptable documentation.

23.

A copy of valid photo identification.

See page 6, Categories I and II, for Acceptable Forms of Identification.

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.

24.

Proof of residency during the time the disputed charges occurred.

See page 6, Category III, for Acceptable Proof of Residency.

25.

A copy of the report you filed with the police or sheriff’s department must be included.

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Id Theft Affidavit Page 5