INITIAL VICTIM OF IDENTITY THEFT STATEMENT AND

FRAUDULENT ACCOUNT INFORMATION REQUEST- Credit Issuers or Merchants

 

Date:______________

Sent certified, return receipt mail:Number ______________________

 

 

TO:††††††††††††††††††††††††††††† [Credit Issuer]†† ††††††††††† FAX

 

ACCOUNT NO. †††††††††††††††††††††††††††††††††††††††††††† REFERENCE NO.

 

FROM:††††† [Your Name]

 

 

I have learned that an unauthorized account has been opened with your company or bank. I did not open this account and have not given permission to anyone else to open this account for me. I have not benefited by this account. You shall consider this account to be fraudulent and a case of identity theft.

 

Below is my identifying information. I have filed a report with my local police department.

Further, credit issuers must provide that documentation and information to a police agency designated by the impersonated party. I am designating the below named detective(s)/prosecutors as additional recipients of all account information and documents.

 

Application Records or screen prints of Internet/phone applications

††††††††††† Statements, Billing and Payment Records

Transaction Records/Charge Slips

Log of outgoing calls if a cell phone account or telephone utility

Investigatorís Summary

Delivery addresses

Any other documents associated with the account

All records of phone numbers used to activate the account or to access the account

 

Additionally, I hereby request you immediately start an investigation, and remove any entries of this account, the application or inquiry records and collection notices from my credit report at once. I also wish to speak with a fraud investigator within 30 days about the status of this case. Once resolved, I expect a letter of clearance to be sent to me within 10 days.

 

Do not sell, distribute, trade, exchange, share, donate, giveaway and/or transfer information about this fraudulent account with any other entity except with the designated law enforcement agencies and prosecutors involved in this case.

 

Please notify any collection agencies that you may have sent this account to. Please do not assign this account to another collection agency. So far these criminals have stolen approximately$______ in checks or credit charges in my name. We suspect there will be more until they are caught.

 

Be advised that reporting these items to the credit bureaus as collection items or continuing to pursue these debts from me would be considered a violation of the Fair Credit Reporting Act.††

 

Victim Information

 

1.†† My full legal name is:________________________________

             

            (If different from above) When the events described in this affidavit took place, I was known as: ________________________________________

 

2.       My birth date is (day/month/year): ____________________

 

3.       My Social Security number is________________________________

 

4.       My driverís license or identification card number is: State________#________________

 

5.       My current address is: ________________________________________________________

 

City:___________________________State:_________________Zip Code:____________

 

6.       I have lived at this address since _____________________________(month/year)

 

7.       (If different from above) When the events described in this affidavit took place, my address was: ________________________________________________________

 

City:____________________________State:_________________Zip Code:_________

 

8.       I lived at that address from __________ until __________(month/year)

 

9.       My daytime telephone number is (____)___________________Cell (___) ______________

 

10.   My evening telephone number is (____)___________________

 

11.   My e-mail address is_________________________

 

How the Fraud Occurred (Check all that apply):

 

___ I did not authorize anyone to use my name or personal information to seek the money, credit, loans, goods or services described in this report.

 

___ I did not receive any benefit, money, goods, or services as a result of the events described in this report.

 

___ My identification documents (ie., credit cards; birth certificate; driver's license; Social Security card, etc.)  were stolen were lost on or about _____________(day/month/year)

 

___ I donít know who the imposter is at this time or how this happened.

 

___ I have proof that the following person(s) used my information (for example, my name, address, date of birth, existing account numbers, Social Security number, motherís maiden name, etc.) or identification documents to obtain money, credit, loans, goods, or services without my knowledge or authorization: (only fill out if you are certain)

_________________________________†† _____________________________________

Name(if known) †††††††††††††††††††††††††††††††† †††††††††Name(if known)

 

________________________________†† _____________________________________

Address (if known)††††††††††††††††††††††††††††††† †††††††† Address (if known)

 

_________________________________†† _____________________________________

Phone number(s) (if known)†††††††††††††††††† †††††††† Phone number(s) (if known)

 

_________________________________†† _____________________________________

additional information (e.g. relationship) additional information (if known)

 

A report has been made with the following police/sheriffís department. If you are unable to obtain a report or report number from the police, please indicate that by checking here _____. Instead of a police report I filed an official affidavit with the following agency ___________________ (case #________)

 

Name of agency: _________________________________________________

Case #__________________________________________________________

Name of investigator if known: ______________________________________

Contact information for law enforcement: (address/phone)________________

_______________________________________________________________

 

 

Signature of victim:_______________________________†† Date _______________

 

I declare under penalty of perjury that this declaration is true and correct to the best of my knowledge. Knowingly submitting false information on this affidavit could subject me to criminal prosecution for perjury.

 

Have one witness (non-relative) sign below that you completed and signed this declaration.)

 

Witness:

 

___________________________________†††††††††† __________________________________

(signature)††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† (printed name)

 

___________________________________††††††††††† _______________________

(date)†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† (telephone number)

 

List of enclosed documents: