Ldentity Theft Victim'S Complaint And Affidavit

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ldentity Theft Victim's Complaint and Affidavit
A voluntary form for filing a report with law enforcement, ond disputes with credit reporting ogencies ond creditors obout
identity theft-related problems. Visit ftc.govlidtheft to use o secure online version thot you con print for your records.
Before completing tfiis form:
I . Place a fraud alert on your credit reports, and review the reports for signs of fraud.
2. Clce the accounts thx you know, or beliwe, have been tampercd with or opened fraudulently.
Now
Leare (3)
blank until
you provide
this form to
someone with
a legitimate
business need,
like when you
are filing your
report at the
police station
or sending
the form
to a credit
reporting
aSency to
corect your
credit report.
( t )
(2)
( 3 )
(4)
(s)
My full legal name:
First
My date of birth:
mmlddlyyyy
My Social Security number:
My driver's license:
Sr"*
My current street address:
Number & Street Name
Apartment, Suite, etc.
City
I have lived at this address since
My daytime phone: (_)
My evening phone: (_)
Zip Code
Country
(6)
(7)
(8)
(e)
mmlWW
My email:
My full legal name was:
My address was:
Number & Street Name
Apartment, Suite, etc.
At the Time of the Fraud
skip (8) - (10)
if your
information
has not
cfianged sirrce
the fraud.
( t 0 )
My email:
State
My evening phone: (_)
City
Zip Code
Country
My daytime phone: (_)
fhe hpmo*
Redgioa Act requires the FTC to d;splry a valid control rnnnber (in dris casg OMB comol #30844047)
before we can collect - or sponsor the collection of - pur infiorrnxion, or require you to pevide it.
H - 1

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