Identity Theft Passport Request Victim Information Sheet printable pdf download

STATE OF OKLAHOMA

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Identity Theft Passport Request

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VICTIM INFORMATION SHEET

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NAME: __________________________________________________

______________________________

LAST

FIRST

MIDDLE

HOME PHONE: (

) _________

FOR STATISTICAL PURPOSES ONLY:

WORK PHONE: (

) _________

DATE OF BIRTH: __________ SEX: _____ RACE: _____

MAILING

ADDRESS:

_________________________________________

DATE YOU BECAME AWARE

_________________________________________

OF THEFT: _____________________________________________________

_________________________________________

CITY/COUNTY & STATE WHERE THEFT

_________________________________________

OCCURRED: ___________________________________________________

_________________________________________

E-MAIL:

_________________________________________

LOCALITY WITH WHICH YOU FILED POLICE REPORT(S): ___________________________________________________________________

NAME & PHONE NUMBER OF OFFICER WHO TOOK YOUR REPORT: ________________________________________________________

COPY OF POLICE REPORT ATTACHED? (Report must be filed in Oklahoma.)

YES _______________ NO _______________

NAME OF COURT THAT ISSUED EXPUNGEMENT ORDER/DATE OF ORDER: _________________________________________________

HAS THE PERSON WHO STOLE YOUR INFORMATION BEEN IDENTIFIED? YES _______________ NO _______________

IF SO, HAS THE SUSPECT BEEN ARRESTED?

YES _______________ NO _______________ DON’T KNOW _______________

IF YES, GIVE THE NAME OF THAT SUSPECT:

____________________________________________________________________________

TYPE OF THEFT/INVOLVEMENT: Credit Card(s)

SSN Misuse

Driver’s Lic.

Passport

Stolen Checks

Mail

ATM

Income Tax Fraud

Civil/Crim. Judgment

Insurance Coverage

Ind. Dept. Store Accts.

GIVE BRIEF DESCRIPTION OF THE INCIDENT(S) OF YOUR ID THEFT: ______________________________________________________

__________________________________________________________________________________________________________________________________

(PLEASE CONTINUE ON BACK OF THIS FORM, IF NECESSARY.)

PLEASE READ BEFORE SIGNING: PLEASE KNOW THAT, IN ACCORDANCE WITH §589 OF TITLE 21, OKLAHOMA STATE

STATUTES, IT SHALL BE UNLAWFUL FOR ANY PERSON TO GIVE FALSE REPORTS TO LAW ENFORCEMENT OFFICIALS.

VIOLATIONS OF THIS PROVISION WILL BE PROSECUTED TO THE FULLEST EXTENT OF THE LAW.

BY SIGNING THIS REPORT, I ATTEST THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE, AND I

ACKNOWLEDGE THAT I DID FILE AN ACCURATE AND TRUE POLICE REPORT OF THIS INCIDENT, A COPY OF WHICH

IS ATTACHED.

SIGNATURE: __________________________________________________________ TODAY’S DATE: _____________________________________

RETURN THIS FORM TO:

IDENTITY THEFT PASSPORT UNIT

PRINT FORM

OKLAHOMA STATE BUREAU OF INVESTIGATION

6600 NORTH HARVEY

OKLAHOMA CITY, OK 73116

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PLEASE INFORM THIS OFFICE, IN WRITING, OF ANY CHANGES IN YOUR

ADDRESS.

The Identity Theft Passport Unit of the OSBI can be contacted by telephone at #405/848-6724.

Identity Theft Passport Request Victim Information Sheet

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