Form of Identity Theft Affidavit - California - Edit, Fill, Sign Online

H-1

Leave (3)

blank until

you provide

this form to

someone with

a legitimate

business need,

like when you

are filing your

report at the

police station

or sending

the form

to a credit

reporting

agency to

correct your

credit report.

Skip (8) - (10)

if your

information

has not

changed since

the fraud.

Now

About You (the victim)

Identity Theft Victim’s Complaint and Affidavit

A voluntary form for filing a report with law enforcement, and disputes with credit reporting agencies and creditors about

identity theft-related problems. Visit ftc.gov/idtheft to use a secure online version that you can print for your records.

Before completing this form:

1. Place a fraud alert on your credit reports, and review the reports for signs of fraud.

2. Close the accounts that you know, or believe, have been tampered with or opened fraudulently.

(1) My full legal name: ________________________________________________

First Middle Last Suffix

(2) My date of birth: __________________

mm/dd/yyyy

(3) My Social Security number: ________-______-__________

(4) My driver’s license: _________ ___________________

State Number

(5) My current street address:

____________________________________________________________________________

Number & Street Name Apartment, Suite, etc.

_______________________________________________________________

City State Zip Code Country

(6) I have lived at this address since ____________________

mm/yyyy

(7) My daytime phone: (____)___________________

My evening phone: (____)___________________

My email: ______________________________________

At the Time of the Fraud

(8) My full legal name was: ____________________________________________

First Middle Last Suffix

(9) My address was: _________________________________________________

Number & Street Name Apartment, Suite, etc.

_______________________________________________________________

City State Zip Code Country

The Paperwork Reduction Act requires the FTC to display a valid control number (in this case, OMB control #3084-0047)

before we can collect – or sponsor the collection of – your information, or require you to provide it.

Average time to complete: 10 minutes

(10) My daytime phone: (____)_________________ My evening phone: (____)_________________

My email: _____________________________________

H-2

(11) I did OR did not authorize anyone to use my name or personal information to

obtain money, credit, loans, goods, or services — or for any

other purpose — as described in this report.

(12) I did OR did not receive any money, goods, services, or other benefit as a

result of the events described in this report.

(13) I am OR am not willing to work with law enforcement if charges are brought

against the person(s) who committed the fraud.

(14) I believe the following person used my information or identification

documents to open new accounts, use my existing accounts, or commit other

fraud.

Victim’s Name _______________________________ Phone number (____)_________________ Page 2

Declarations

About You (the victim) (Continued)

(14):

Enter what

you know

about anyone

you believe

was involved

(even if you

don’t have

complete

information).

Name: ___________________________________________________

First Middle Last Suffix

Address: __________________________________________________

Number & Street Name Apartment, Suite, etc.

__________________________________________________________

City State Zip Code Country

Phone Numbers: (____)_______________ (____)________________

Additional information about this person: _____________________________________

_______________________________________________________________________

About the Fraud

H-3

Victim’s Name _______________________________ Phone number (____)_________________ Page 3

(15) Additional information about the crime (for example, how the identity thief

gained access to your information or which documents or information were

used):

________________________________________________________________

______________________________________________________________________________

About the Information or Accounts

(17) The following personal information (like my name, address, Social Security number, or date of

birth) in my credit report is inaccurate as a result of this identity theft:

(A) __________________________________________________________________________

(B) __________________________________________________________________________

(C) __________________________________________________________________________

(18) Credit inquiries from these companies appear on my credit report as a result of this identity

theft:

Company Name: _______________________________________________________________

(14) and (15):

Attach

additional

sheets as

needed.

(16): Reminder:

Attach copies

of your identity

documents

when sending

this form to

creditors

and credit

reporting

agencies.

(16) I can verify my identity with these documents:

A valid government-issued photo identification card (for example, my driver’s

license, state-issued ID card, or my passport).

If you are under 16 and don’t have a photo-ID, a copy of your birth certificate or

a copy of your official school record showing your enrollment and legal address is

acceptable.

Proof of residency during the time the disputed charges occurred, the loan

was made, or the other event took place (for example, a copy of a rental/lease

agreement in my name, a utility bill, or an insurance bill).

Documentation

H-4

___________________________________________________________________

Name of Institution Contact Person Phone Extension

___________________________________________________________________

Account Number Routing Number Affected Check Number(s)

Account Type: Credit Bank Phone/Utilities Loan

Government Benefits Internet or Email Other

Select ONE:

This account was opened fraudulently.

This was an existing account that someone tampered with.

___________________________________________________________________

Date Opened or Misused (mm/yyyy) Date Discovered (mm/yyyy) Total Amount Obtained ($)

___________________________________________________________________

Name of Institution Contact Person Phone Extension

___________________________________________________________________

Account Number Routing Number Affected Check Number(s)

Account Type: Credit Bank Phone/Utilities Loan

Government Benefits Internet or Email Other

Select ONE:

This account was opened fraudulently.

This was an existing account that someone tampered with.

___________________________________________________________________

Date Opened or Misused (mm/yyyy) Date Discovered (mm/yyyy) Total Amount Obtained ($)

___________________________________________________________________

Name of Institution Contact Person Phone Extension

___________________________________________________________________

Account Number Routing Number Affected Check Number(s)

Account Type: Credit Bank Phone/Utilities Loan

Government Benefits Internet or Email Other

Select ONE:

This account was opened fraudulently.

This was an existing account that someone tampered with.

___________________________________________________________________

Date Opened or Misused (mm/yyyy) Date Discovered (mm/yyyy) Total Amount Obtained ($)

Victim’s Name _______________________________ Phone number (____)_________________ Page 4

(19) Below are details about the different frauds committed using my personal information.

(19):

If there were

more than three

frauds, copy this

page blank, and

attach as many

additional copies

as necessary.

Enter any

applicable

information that

you have, even if

it is incomplete

or an estimate.

If the thief

committed two

types of fraud at

one company,

list the company

twice, giving

the information

about the two

frauds separately.

Contact Person:

Someone you

dealt with, whom

an investigator

can call about this

fraud.

Account Number:

The number of

the credit or

debit card, bank

account, loan, or

other account

that was misused.

Dates: Indicate

when the thief

began to misuse

your information

and when you

discovered the

problem.

Amount Obtained:

For instance,

the total amount

purchased with

the card or

withdrawn from

the account.

H-5

Victim’s Name _______________________________ Phone number (____)_________________ Page 5

(20) One way to get a credit reporting agency to quickly block identity theft-

related information from appearing on your credit report is to submit a

detailed law enforcement report (“Identity Theft Report”). You can obtain

an Identity Theft Report by taking this form to your local law enforcement

office, along with your supporting documentation. Ask an officer to witness

your signature and complete the rest of the information in this section. It’s

important to get your report number, whether or not you are able to file in

person or get a copy of the official law enforcement report. Attach a copy of

any confirmation letter or official law enforcement report you receive when

sending this form to credit reporting agencies.

Select ONE:

I have not filed a law enforcement report.

I was unable to file any law enforcement report.

I filed an automated report with the law enforcement agency listed

below.

I filed my report in person with the law enforcement

officer and agency listed below.

____________________________________________________________________

Law Enforcement Department State

____________________________ _____________________

Report Number Filing Date (mm/dd/yyyy)

____________________________________________________________________

Officer’s Name (please print) Officer’s Signature

____________________________ (____)_______________

Badge Number Phone Number

Did the victim receive a copy of the report from the law enforcement officer? Yes OR No

Victim’s FTC complaint number (if available): ________________________

Your Law Enforcement Report

(20):

Check “I have

not...” if you have

not yet filed a

report with law

enforcement or

you have chosen

not to. Check “I

was unable...” if

you tried to file

a report but law

enforcement

refused to take it.

Automated report:

A law

enforcement

report filed

through an

automated

system, for

example, by

telephone, mail,

or the Internet,

instead of a

face-to-face

interview with a

law enforcement

officer.

H-6

As applicable, sign and date IN THE PRESENCE OF a law enforcement officer, a notary, or

a witness.

(21) I certify that, to the best of my knowledge and belief, all of the information on and attached to

this complaint is true, correct, and complete and made in good faith. I understand that this

complaint 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 violate federal, state, or local criminal statutes, and may result in a fine,

imprisonment, or both.

_______________________________________ _________________________________________

Signature Date Signed (mm/dd/yyyy)

Signature

(22) If you do not choose to file a report with law enforcement, you may use this form as an Identity

Theft Affidavit to prove to each of the companies where the thief misused your information that

you are not responsible for the fraud. While many companies accept this affidavit, others require

that you submit different forms. Check with each company to see if it accepts this form. You

should also check to see if it requires notarization. If so, sign in the presence of a notary. If it

does not, please have one witness (non-relative) sign that you completed and signed this Affidavit.

_______________________________________

Notary

Witness:

_______________________________________ _________________________________________

Signature Printed Name

_______________________________________ _________________________________________

Date Telephone Number

Your Affidavit

Victim’s Name _______________________________ Phone number (____)_________________ Page 6

Fillable Printable Form of Identity Theft Affidavit - California

Fillable Printable Form of Identity Theft Affidavit - California

Form of Identity Theft Affidavit - California