Identity Theft Victim'S Complaint And Affidavit
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Identity Theft Victim’s Complaint and Affidavit
A voluntary form for filing a report with law enforcement, and disputes with credit reporting agencies and creditors about
identity theft-related problems. Visit ftc.gov/idtheft to use a secure online version that you can print for your records.
Before completing this form:
1.
Place a fraud alert on your credit reports, and review the reports for signs of fraud.
2.
Close the accounts that you know, or believe, have been tampered with or opened fraudulently.
About You (the victim)
Now
Leave (3)
(1)
My full legal name: ________________________________________________
blank until
First
Middle
Last
Suffix
you provide
(2)
My date of birth: __________________
this form to
mm/dd/yyyy
someone with
a legitimate
(3)
My Social Security number: ________-______-__________
business need,
like when you
(4)
My driver’s license: _________
___________________
are filing your
State
Number
report at the
(5)
My current street address:
police station
or sending
____________________________________________________________________________
the form
Number & Street Name
Apartment, Suite, etc.
to a credit
reporting
_______________________________________________________________
agency to
City
State
Zip Code
Country
correct your
credit report.
(6)
I have lived at this address since ____________________
mm/yyyy
(7)
My daytime phone: (____)___________________
My evening phone: (____)___________________
My email: ______________________________________
At the Time of the Fraud
Skip (8) - (10)
(8)
My full legal name was: ____________________________________________
if your
information
First
Middle
Last
Suffix
has not
(9)
My address was: _________________________________________________
changed since
Number & Street Name
Apartment, Suite, etc.
the fraud.
_______________________________________________________________
City
State
Zip Code
Country
(10)
My daytime phone: (____)_________________ My evening phone: (____)_________________
My email: _____________________________________
The Paperwork Reduction Act requires the FTC to display a valid control number (in this case, OMB control #3084-0047)
before we can collect – or sponsor the collection of – your information, or require you to provide it.
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Parent category: Legal