York County Sheriff'S Office Identity Theft Victim'S Packet Page 9
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17Name_______________________________ _________________________________ Page 4
York County Sheriff's Office Report Number__________________________________
_____________________________________________________________________________________
Documentation Checklist:
Please indicate the supporting documentation you are able to provide to the companies you notify.
Attach copies (NOT originals) to the affidavit before sending it to the companies. Circle all that apply.
20. A copy of a valid government issued photo identification card (for example, your driver’s license,
state issued ID card, or your passport). If you are under 16 and do not have a photo ID, you may
submit a copy of your birth certificate or a copy of your official school records showing your
enrollment and place of residence.
21. Proof of residency during the time the disputed bill occurred, the loan was made, or the other
event took place (for example, a rental/lease agreement in your name, a copy of a utility bill, or
a copy of an insurance bill).
22. A copy of the report filed with the police or sheriff’s office. If you are unable to obtain a report
or report number from the police, please indicate that in item 19. Some companies only need
the report number, not a copy of the report. You may want to check with each company.
I certify that, to the best of my knowledge and belief, all the information on and attached to this
affidavit is true, correct and complete and made in good faith. I also understand that this affidavit
or the information it contains may be made available to federal, state, and/or local law enforcement
agencies for such action within their jurisdiction as they deem appropriate. I understand that
knowingly making any false or fraudulent statement or representation to the government may
constitute a crime and may result in imposition of a fine or imprisonment or both.
__________________________________
______________________________
Signature
Date
Check with each company. Creditors sometime require notarization. If they do not please have one
witness (non-relative) sign below that you completed and signed this affidavit.
__________________________________
______________________________
Notary
Date
Witness:
__________________________________
______________________________
Signature
Printed Name
__________________________________
______________________________
Date
Telephone Number
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