Phoenix Police Department'S Identity Theft Victim'S Packet Page 6
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13Name ______________________ Phoenix Police Department Report Number __________________________Page 2
My identification documents (for example, credit cards; birth certificates; driver's license;
Social Security card; etc.) were:
13.
stolen
lost on or about ________________________________
(day/month/year)
To the best of my knowledge and belief, the following person(s) used my information (for example,
my name, address, date of birth, existing account numbers, Social Security number, mother's
maiden name, etc.) or identification documents to get money, credit, loans, goods or services
without my knowledge or authorization:
14.
_________________________________
____________________________________
Name (if known)
Name (if known)
_________________________________
____________________________________
Address (if known)
Address (if known)
________________________________
___________________________________
Phone number(s) (if known)
Phone number(s) (if known)
________________________________
___________________________________
Additional information
Additional information
I do NOT know who used my information or identification documents to get money, credit,
loans, goods or services without my knowledge or authorization
15.
Additional comments: (For example, description of the fraud, which documents or
information were used or how the identity theif gained access to your information)
16.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(Attach additional pages as necessary.)
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