Identity Theft Intake Form - South Carolina Department Of Consumer Affairs
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4S
C
D
C
A
OUTH
AROLINA
EPARTMENT OF
ONSUMER
FFAIRS
2221 Devine St.
STE. 200
PO Box 5757
Columbia, SC 29250
800‐922‐1594
Nov 2014
IDENTITY THEFT INTAKE FORM
Please fill out this form as completely as possible, leaving out all sensitive information (such as your SSN or account
numbers). If you are simply looking for general information on identity theft, please contact us directly.
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Tell Us About Yourself:
Mr.
Mrs.
Ms.
Name:
___________________________________________________________________________
Mailing Address:
City:
_______________________________________
_________________________
State:
Zip Code
Daytime Telephone Number: ( )
________________
____________
_______________
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Age Range:
18‐25
26‐35
36‐45
46‐55
56‐65
66‐75
76+
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Preferred Method of Contact:
Mail
Telephone
E‐mail :
_______________________________
Identity Theft Background Questions
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How did you learn you were a victim of identity theft?
Credit Report
Collection Notice
IRS Letter
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Bank Notice
Other:
_____________________________________________________________
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Have you received a Security Breach notice?
Yes
No
If so, please list the name of the company(ies):
_______________________________________________
What personal information was included in the breach (e.g. SSN, bank account number, etc.)? Please list:
________________________________________________________________________________
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Have you filed a police report?
Yes
No If yes, when?
__________
With:______________________________________________________________________________________________________________________________
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Have you filed an Identity Theft Affidavit with the FTC?
Yes
No If yes, when?
____________
Credit Report Information
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Have you reviewed your credit report(s) within the last year?
Yes
No
If yes, which credit reports did you review?
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TransUnion Date:
Equifax Date:
Experian Date:
__________
__________
__________
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Have you placed a Fraud Alert on your credit report(s) within the last 90 days?
Yes
No
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Which agency did you contact to place the Fraud Alert?
TransUnion
Equifax
Experian
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Have you placed a Security Freeze on your credit report(s)?
Yes
No
Which agency(ies) did you contact to place your Security Freeze?
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TransUnion Date:
Equifax Date:
Experian Date:
__________
__________
__________
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