Identity Theft Victim'S Complaint And Affidavit Page 4
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6Victim’s Name _______________________________ Phone number (____)_________________ Page 4
(19)
Below are details about the different frauds committed using my personal information.
(19):
___________________________________________________________________
If there were
Name of Institution
Contact Person
Phone
Extension
more than three
frauds, copy this
___________________________________________________________________
page blank, and
Account Number
Routing Number
Affected Check Number(s)
attach as many
additional copies
Account Type:
Credit
Bank
Phone/Utilities
Loan
as necessary.
Government Benefits
Internet or Email
Other
Enter any
Select ONE:
applicable
information that
This account was opened fraudulently.
you have, even if
This was an existing account that someone tampered with.
it is incomplete
___________________________________________________________________
or an estimate.
Date Opened or Misused (mm/yyyy)
Date Discovered (mm/yyyy)
Total Amount Obtained ($)
If the thief
committed two
types of fraud at
___________________________________________________________________
one company,
Name of Institution
Contact Person
Phone
Extension
list the company
___________________________________________________________________
twice, giving
Account Number
Routing Number
Affected Check Number(s)
the information
about the two
Account Type:
Credit
Bank
Phone/Utilities
Loan
frauds separately.
Government Benefits
Internet or Email
Other
Contact Person:
Someone you
Select ONE:
dealt with, whom
This account was opened fraudulently.
an investigator
This was an existing account that someone tampered with.
can call about this
fraud.
___________________________________________________________________
Date Opened or Misused (mm/yyyy)
Date Discovered (mm/yyyy)
Total Amount Obtained ($)
Account Number:
The number of
the credit or
___________________________________________________________________
debit card, bank
Name of Institution
Contact Person
Phone
Extension
account, loan, or
___________________________________________________________________
other account
that was misused.
Account Number
Routing Number
Affected Check Number(s)
Dates: Indicate
Account Type:
Credit
Bank
Phone/Utilities
Loan
when the thief
Government Benefits
Internet or Email
Other
began to misuse
your information
Select ONE:
and when you
This account was opened fraudulently.
discovered the
problem.
This was an existing account that someone tampered with.
___________________________________________________________________
Amount Obtained:
For instance,
Date Opened or Misused (mm/yyyy)
Date Discovered (mm/yyyy)
Total Amount Obtained ($)
the total amount
purchased with
the card or
withdrawn from
the account.
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