Phoenix Police Department'S Identity Theft Victim'S Packet Page 9
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13Name ______________________ Phoenix Police Department Report Number __________________________Page 5
Fraudulent Account Statement
Completing the Statement
• Make as many copies of this page as you need. Complete a separate page for each
company you’re notifying and only send it to that company. Include a copy of your
signed affidavit.
• List only the account(s) you’re disputing with the company receiving this form. See
the example below.
• If a collection agency sent you a statement, letter or notice about the fraudulent
account, attach a copy of that document (NOT the original).
I declare (check all that apply):
As a result of the event(s) described in the ID Theft Affidavit, the following account(s) was/were opened
at your company in my name without my knowledge, permission or authorization using my personal
information or identifying documents:
Creditor
Account
Type of unauthorized
Date
Amount/Value
Name/Address
Number
Credit/goods/services
Issued or
provided
Provided by creditor
Opened
(the amount charged or
(
the company that opened
the cost of the
If known)
(if known)
(
the account or provided the
goods/services)
goods or services)
Example
Example National Bank
01234567-89
01/05/2002
$25,500.00
Auto Loan
22 Main Street
Columbus, OH 22722
During the time of the accounds described above, I had the following account open with your company:
Billing name: ___________________________________________________________________
Billing address: _________________________________________________________________
Account number: ________________________________________________________________
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