Identity Theft Intake Form - South Carolina Department Of Consumer Affairs Page 3
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4Section 2 – Tax Theft
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15. Were you notified of an identity theft related issue by the IRS?
Yes
No
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16. Did the IRS withhold all or part of your refund?
Yes
No
If yes, for what reason (e.g. refund offset, balance due, etc.)? Please list:
___________________________
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17. Has the IRS notified you that more than one tax return was filed with your information?
Yes
No
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18. Have you contacted the IRS?
Yes
No Date:
__________
Section 3 – Benefits Theft
19. Were you denied any of the following benefits? Check any that apply.
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Medicare
Disability
Welfare/Social Service
Social Security
Unemployment
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If yes, for what reason?
Already Receiving Benefits
Not Eligible (e.g. exceed income, did not meet
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requirements, etc.)
Other Reason:
__________________________________________________
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Have you contacted the benefits agency(ies)?
Yes
No
If yes, please list the name(s) of the agency(ies) and date(s) contacted:
____________________________
Section 4 – Medical Care Theft
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20. Have you received a bill for any medical services you did not receive?
Yes
No
21. Have you received an explanation of benefits (EOB) from your insurance company for an office visit,
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medical treatment, or medication that you did not receive?
Yes
No
22. Have you received information from a health insurance company for a policy you did not sign up for?
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Yes
No
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23. Have you contacted the company/health care provider?
Yes
No
If yes, please list the name(s) of the company and date(s) contacted:
______________________________
Section 5 – Criminal ID Theft
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24. Are there any warrants in your name for crimes you did not commit?
Yes
No
Unknown
If yes, have you contacted a court clerk or law enforcement agency to find out what the warrant is for and
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where it originated?
Yes
No
If yes, please list the name(s) of the agency(ies) and date(s) contacted:
____________________________
Section 6 – Other Forms of Identity Theft
25. Has your application to rent an apartment or house been refused due to identity theft or incorrect
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information on your credit report?
Yes
No
26. Does an inquiry from a landlord or rental company that you do not recognize appear on your credit
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report?
Yes
No
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27. Has someone used your information to get a job?
Yes
No
Unknown
28. Have you requested an earnings statement and/or benefits estimate from the Social Security
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Administration?
Yes
No
Additional Information
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29. Have you experienced a monetary loss as the result of the theft?
Yes
No
If yes, approximately how much? (Optional): $
______________
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