Notice Of Identity Theft - Affidavit Of Fact (Page 3 of 3) in pdf

Notice Of Identity Theft - Affidavit Of Fact Page 3

A report has been made with the following police/sheriff’s department. If you are unable to

obtain a report or report number from the police, please indicate that by checking here _____.

Name of agency: ________________________________________________________

Name of investigator if known:______________________________________________

Contact information for law enforcement: _____________________________________

Report Number: _______________________

_______________________________

Signature of provider of information

Date

I declare under penalty of perjury that this declaration is true and correct to the best of my

knowledge. I understand that submitting false information on this affidavit could subject me to

criminal prosecution for perjury.

Attachments:

____ Police report - if available

____ Death Certificate (or copy)- required

____ Power of Attorney – if appropriate

____ Proof that requester is Executor or Trustee of estate – if appropriate

____ Proof of relationship – if appropriate

____ Medical documentation.

ITRC Letter Form 117-2

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Notice Of Identity Theft - Affidavit Of Fact Page 3