Ldentity Theft Victim'S Complaint And Affidavit Page 4
ADVERTISEMENT
1
2
3
4
5
6
7
8Victimb Nome
Phone number (_)
(19)
Below are details about the different frauds committed using my personal information.
Name of Instinrtion
Contact Person
Phone
Extension
Account Number
Routing Number
Affected Check Number(s)
Account Type: tr Credit tr Bank tr Phone/Utilities El Loan
[f Government Benefits fl lnternet or Email E Other
Select ONE:
tr This account was opened fraudulently.
BThis was an existing account that someone tampered with.
Date Opened or Misused (mm/yfyy)
Date Discovered (mm/yyry)
lbtalAmount Obtain€d ($)
Name of Institution
Contact Person
Phone
Extension
Account Number
Routing Number
Affected Check Number(s)
Account Type: tr Credit
D Bank tr Phone/Utilities E Loan
fl Government Benefits E lnternet or Email fl Other
Select ONE:
il This account was opened fraudulently.
tr This was an existing account that someone tampered with.
Date Opened or Misused (mm/fffy)
Date Discovered (mmlyyyy)
Total Amount Obtained ($)
Name of lnsthution
Contact Percon
Phone
Extension
Account Number
Routing Number
Affected Check Number(s)
AccountT).pE: trCredit
$Bank EPhone/Utilities EILoan
O Government Benefig El Internet or Email tr Other
Select ONE:
tr This account was opened fraudulently.
trThis was an existing account that someone tampered with.
Dxe Opened or. yli$$ed (mmlyyW)
Date Discorered (mmlyyyy,)
TotalAmounr Obtained ($)
Poge 4
(t e):
lf there were
more than three
frauds, copy this
page blank, and
attach as many
additional copies
as neces$rry.
Enter any
applicable
information that
you have, even if
it is incomplete
or an estirnate.
lf the thief
committed two
qrpes of fraud at
one comPanx
list the company
twice, giving
the information
about the two
frauds separately.
Contoct furson:
Someone you
&dtwith,
whom
an investigator
can call abut this
fraud.
AccountNumber:
The number of
the credk or
debit card, bank
account, loan, or
other account
tha( was misused.
Dates: lndicate
when the thief
began to misuse
your information
and when you
discovered the
problem.
AmauntObtaind:
For instance,
the tobl arnount
purchased with
the card or
withdrawn from
the account.
H 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal