Sworn Statement Of Identity Theft
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3SWORN STATEMENT OF IDENTITY THEFT
[TO BE COMPLETED BY CUSTOMER AND PROVIDED TO FINANCIAL INSTITUTION]
Please complete this form and return it to your financial institution with a copy of the police report or the
case/offense number from a police department of the reported offense under Section 32.51, Penal Code. If you
have not closed all accounts at your financial institutions that were compromised by the reported offense, you
should do so immediately. (See page three of this form for a description of offenses under §32.51, Penal Code.)
1. Identification:
Name:
Mailing Address:
City:
State:
Zip:
Phone Number: Home
Work:
Date of Birth:
Driver License Number:
State:
(If you don’t have a driver license, you must present one of the following forms of government issued identification.)
State Issued Identification
State:
ID Number:
Military Identification
ID Number:
United States Passport
ID Number:
Foreign Passport
Country:
ID Number:
Other – Type:
ID Number:
2. Check one.
(If you do not attach the police report, you must provide the police case or offense number.)
A copy of the police report is attached to this sworn statement.
A copy of the police report is not attached, but the police case or offense number is: ________________________
3. Identification of accounts at this financial institution that were compromised by the alleged offense:
Please list the account numbers of the compromised accounts. Also list the check numbers of any checks that
have been lost, stolen, or compromised, if known.
Account Number
Name(s) on Account
Check Number(s) or Range, if Known
a.
b.
c.
d.
e.
f.
Check here if this list is continued on the back of this page.
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Texas Department of Banking
For Financial Institution Use
TXFC32.51-2008.03.01
Rev. 03-2008
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