Sent certified, return receipt mail:† Number ______________________
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.††
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: ________________________________________________________
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: ________________________________________________________
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 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.
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: _________________________________________________
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.)
(signature)††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† (printed name)
(date)†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† (telephone number)
List of enclosed documents: