Ldentity Theft Victim'S Complaint And Affidavit (Page 6 of 8) in pdf

Ldentity Theft Victim'S Complaint And Affidavit Page 6

Victim's Nome

Phone number (_)

Poge 6

As applicable, sign and date ,N THE PRESENCE OF a law enforcement officer, a notary or

a witness.

( 2 t )

I certify that, to the best of my knowledge and belief, all of the information on and attached to

this complaint is true, correct, and complete and made in good faith. I understand that this

complaint or the information it contains may be made available to federal, state, and/or local

law enforcement agencies for such action within their lurisdiction as they deem appropriate. I

understand that knowingly making any false or fraudulent statement or representation to the

government may violate federal, state, or local criminal statutes, and may result in a fine,

imprisonment, or both.

Signature

Date Signed (mmlddlyyyy)

(22)

lf you do not choose to file a repoft with law enforcement, you may use this form as an ldenrity

Theft Affidavit to prove to each of the companies where the thief misused your information that

you are not responsible for the fraud. While many companies accept this affidavit, others require

that you submit different forms. Check with each company to see if it accepts this form. You

should also check to see if it requires notarization. lf so, sign in the presence of a notary. lf it

does not, please have one witness (non-relative) sign that you completed and signed this Affidavit.

NotarT

Witness:

Signature

Printed Name

Date

Telephone Number

H-6

Ldentity Theft Victim'S Complaint And Affidavit Page 6