Identity Theft Victim'S Complaint And Affidavit (Page 5 of 6) in pdf

Victim’s Name _______________________________ Phone number (____)_________________ Page 5

Your Law Enforcement Report

(20):

(20)

One way to get a credit reporting agency to quickly block identity theft-

Check “I have

related information from appearing on your credit report is to submit a

not...” if you have

detailed law enforcement report (“Identity Theft Report”). You can obtain

not yet filed a

report with law

an Identity Theft Report by taking this form to your local law enforcement

enforcement or

office, along with your supporting documentation. Ask an officer to witness

you have chosen

your signature and complete the rest of the information in this section. It’s

not to. Check “I

important to get your report number, whether or not you are able to file in

was unable...” if

person or get a copy of the official law enforcement report. Attach a copy of

you tried to file

a report but law

any confirmation letter or official law enforcement report you receive when

enforcement

sending this form to credit reporting agencies.

refused to take it.

Select ONE:

Automated report:

I have not filed a law enforcement report.

A law

enforcement

I was unable to file any law enforcement report.

report filed

I filed an automated report with the law enforcement agency listed

through an

below.

automated

I filed my report in person with the law enforcement

system, for

officer and agency listed below.

example, by

telephone, mail,

or the Internet,

instead of a

____________________________________________________________________

face-to-face

Law Enforcement Department

State

interview with a

law enforcement

officer.

____________________________

_____________________

Report Number

Filing Date (mm/dd/yyyy)

____________________________________________________________________

Officer’s Name (please print)

Officer’s Signature

____________________________

_____________________

Badge Number

Phone Number

Did the victim receive a copy of the report from the law enforcement officer?

Yes OR

Victim’s FTC complaint number (if available): ________________________

Identity Theft Victim'S Complaint And Affidavit Page 5

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