Ldentity Theft Victim'S Complaint And Affidavit (Page 3 of 8) in pdf

Ldentity Theft Victim'S Complaint And Affidavit Page 3

Victim's Nome

Phone number (_)

(l 5)

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

gained access to your information or which documents or information were

used):

Poge 3

( l6)

| can verify my identity with these documents:

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

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

lf you ore under l6 ond don't have o photo-lD, o copy of your birth certificote or

o copy of your officiol school record showing your enrollment ond legol oddress ls

occeptoble.

I 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).

(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)

(c)

( l8)

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

theft:

Company Name:

t-l 3

(16): Reminder:

Attach copies

of your identity

documents

when sending

this form to

creditors

and credit

reporting

agencies.

Ldentity Theft Victim'S Complaint And Affidavit Page 3