Date:______________
Sent certified, return receipt
mail: Number ______________________
TO: [Credit Issuer] FAX
ACCOUNT
NO. REFERENCE
NO.
FROM: [Your Name]
I have learned that an individual is
passing
_____ Checks numbered xxx to xxx for
___ (bank name, acct #xxx) were stolen. Be advised
that this account was
closed on ____ (date) by the bank upon my request.
_____ Checks have been
fraudulently created by another person using my name and address as the account
holder
_____ Checks have been
fraudulently created by another person using my account number but are not part
of my true account. (if appropriate, add if a
different name was used)
You are hereby being notified that
this is a fraudulent situation and a case of identity theft.
Below is my identifying information.
I have filed a report with my local police department. According to FACTA (effective
June 2, 2004) you will be required to comply with this request within 30 days.
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 you may have
regarding this situation including video surveillence
tape, copies of checks and other transaction records.
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 driver’s license or
identification card number is: State________
#________________
5.
My current address is:
________________________________________________________
City:
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:
8.
I lived at this 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 don’t 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, mother’s 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/sheriff’s department.
I am
unable in my state to file a police report. Instead per FACTA 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: