Ldentity Theft Victim'S Complaint And Affidavit Page 2
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1
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8Victim's Nome
Phone number (_)
Poge 2
Declarations
(r 2 ) |
( 1 3 ) |
( l l )
|
D d i d
O R
D d i d n o t
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.
receive any money goods, services, or other benefit as a
result of the events described in this report.
willing to work with law enforcement if charges are brought
against the person(s) who committed the fraud.
my information or identification
use my existing accounts, or commit other
n d id o R
E did not
l a m
O R
f l a m n o t
( l4)
| believe the following person used
documents to open new accounts,
fraud.
Address:
Number & Street Name
Apartment, Suite, etc
CitY
Phone Numbers: (_)
Zip Code
Country
(_)
State
Additional information about this person:
(ta):
Enter what
you know
about anyone
you believe
was involved
(even if you
don't have
complete
information).
t { " 2
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