Identity Theft Affidavit Form - Wichita Police Department Page 5
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14IDENTITY THEFT AFFIDAVIT
VICTIM INFORMATION
1. My full legal name is
(First)
(Middle)
(Last)
(Jr., Sr., III)
2. (If different from above) When the events described in this affidavit took place, I was known as
(First)
(Middle)
(Last)
(Jr., Sr., III)
3. My date of birth is
__________________________________
(Day/Month/Year)
4. My Social Security number is ____________________________
5. My driver’s license or identification card state and number ____________________________
6. My current address is _________________________________________________________
City ________________________________ State ___________ Zip Code ___________
7. I have lived at this address since ________________
(Month/Year)
8. (If different from above) When the events described in this affidavit took place, my address was
City ________________________________ State ___________ Zip Code ____________
9. I lived at this address (No. 8) from __________________________ until __________________
(Month/Year)
(Month/Year)
10. My daytime telephone number is (_______) ________________________________
My evening telephone number is (_______) ________________________________
HOW THE FRAUD OCCURRED
Check all that apply for items 11-17
□
11.
I did not authorize anyone to use my name or personal information to seek the money,
credit, loans, goods or services described in this document.
□
12.
I did not receive any benefit, money, goods or services as a result of the events described in
this document.
□
13.
My identification documents (i.e., credit cards, birth certificate, driver’s license, Social
□
□
Security card, etc.) were
stolen
lost on or about __________________________.
(Day/Month/Year
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