Phoenix Police Department'S Identity Theft Victim'S Packet (Page 8 of 13) in pdf

Phoenix Police Department'S Identity Theft Victim'S Packet Page 8

Name ______________________ Phoenix Police Department Report Number __________________________Page 4

22.

A copy of the report filed with the police or sheriff's department. 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.

Signature

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 violation of 18 U.S.C. 1001 or

other federal, state or local criminal statutes, and may result in imposition of a fine or imprisonment or both

______________________________________

_____________________________________

(signature)

(date signed)

_______________________________________

(Notary)

[Check with each company. Creditors sometimes require notarization. If they do not, please have one

witness (non-relative) sign below that you completed and signed this affidavit.]

Witness:

______________________________________

___________________________________

(signature)

(printed name)

______________________________________

____________________________________

(date)

(telephone number)

Phoenix Police Department'S Identity Theft Victim'S Packet Page 8