Identity Theft Victim'S Complaint And Affidavit (Page 3 of 6) in pdf

Victim’s Name _______________________________ Phone number (____)_________________ Page 3

(15)

Additional information about the crime (for example, how the identity thief

(14) and (15):

gained access to your information or which documents or information were

Attach

used):

additional

sheets as

________________________________________________________________

needed.

________________________________________________________________

______________________________________________________________________________

Documentation

(16): Reminder:

(16)

I can verify my identity with these documents:

Attach copies

of your identity

A valid government-issued photo identification card (for example, my driver’s

documents

license, state-issued ID card, or my passport).

when sending

If you are under 16 and don’t have a photo-ID, a copy of your birth certificate or

this form to

a copy of your official school record showing your enrollment and legal address is

creditors

and credit

acceptable.

reporting

agencies.

Proof of residency during the time the disputed charges occurred, the loan

was made, or the other event took place (for example, a copy of a rental/lease

agreement in my name, a utility bill, or an insurance bill).

About the Information or Accounts

(17)

The following personal information (like my name, address, Social

Security number, or date of birth) in my credit report is inaccurate as a result of this identity

theft:

(A) __________________________________________________________________________

(B) __________________________________________________________________________

(18)

Credit inquiries from these companies appear on my credit report as a result of this identity

theft:

Company Name: _______________________________________________________________

Identity Theft Victim'S Complaint And Affidavit Page 3

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