Sworn Statement Of Identity Theft (Page 2 of 3) in pdf

Sworn Statement Of Identity Theft Page 2

THE STATE OF TEXAS HAS ESTABLISHED AN ELECTRONIC NOTIFICATION

SYSTEM TO DELIVER INFORMATION TO CHECK VERIFICATION ENTITIES

REGARDING VICTIMS OF OFFENSES UNDER SECTION 32.51, PENAL CODE.

CHECK VERIFICATION ENTITIES USE INFORMATION RECEIVED TO ASSIST

MERCHANTS IN DECIDING WHETHER TO ACCEPT CHECKS AND OTHER

PAYMENT DEVICES PRESENTED TO THEM.

BY SIGNING THIS STATEMENT, YOU ARE:

• Stating under oath that, to the best of your knowledge and belief, you are

the victim of an offense under Section 32.51, Penal Code, relating to the

fraudulent, obtaining, transfer, use or possession of your identifying

information without your consent;

• Requesting that your financial institution close each account identified in

Section 3 above; and

• Authorizing and requesting that your financial institution submit this

information to the electronic notification system.

Signature:

________________________________

STATE OF TEXAS

COUNTY OF ________________

Before me, the undersigned notary, on this day, personally appeared __________________,

known to me to be the person who executed this statement, and made oath that the

statements and representations set forth in this statement are true to the best of his or her

knowledge and belief.

Subscribed and sworn to before me this ___________ day of ______________, _________.

_______________________________________

NOTARY PUBLIC FOR THE STATE OF TEXAS

Texas Department of Banking

For Financial Institution Use

TXFC32.51-2008.03.01

Rev. 03-2008

Sworn Statement Of Identity Theft Page 2