Identity Theft Victim'S Complaint And Affidavit Page 2

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Victim’s Name _______________________________ Phone number (____)_________________ Page 2
About You (the victim) (Continued)
Declarations
(11)
I
did OR
did not
authorize anyone to use my name or personal information to
obtain money, credit, loans, goods, or services — or for any
other purpose — as described in this report.
(12)
I
did OR
did not
receive any money, goods, services, or other benefit as a
result of the events described in this report.
(13)
I
am OR
am not
willing to work with law enforcement if charges are brought
against the person(s) who committed the fraud.
About the Fraud
(14):
(14)
I believe the following person used my information or identification
Enter what
documents to open new accounts, use my existing accounts, or commit other
you know
about anyone
fraud.
you believe
was involved
Name: ___________________________________________________
(even if you
First
Middle
Last
Suffix
don’t have
complete
Address: __________________________________________________
information).
Number & Street Name
Apartment, Suite, etc.
__________________________________________________________
City
State
Zip Code
Country
Phone Numbers: (____)_______________ (____)________________
Additional information about this person: _____________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

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