ID Theft Affidavit - Scottsdale of Arizona - Edit, Fill, Sign Online

Name ______ __________ ______ Scottsdale Pol ice Department Report Number ___________________ Page 1

ID Theft Affidavit

My full legal name is ______________________________________________

Victim Information

1. My full legal name is ___________________________________________________________________

(First) (Middle) (Last) (Jr.,Sr., III)

2. (If different from above) When the events de scribed in this affidavit took place, I was kn

own as

___________________________________________________________________________________

(First) (Middle) (Last)

(Jr., Sr., III)

3. My date of birth is __________________________

(day/month/year)

4. My Social Security Num ber is ____________________________________

5. My driver’s license or identification ca

rd state a

nd number are__________________________

6. My current address is __________________________________________________________________

City_____________________________State_____________________Zip Code__________

7. I have lived at this address since ___________ ______________ _____

(month/year)

8. (If different from above) When the events de scrib

ed in this affidavit took pla

ce, my address

was________________________________________________________________________________

City__________________________________State_______________________Zip Code____________

9. I lived at the address in Item 8 from ____________until____________

(month/year) (month/year)

10. My daytime telephone number is ( ____)__________________ ______

My evening telephone number is (_____)________________________

How the Fraud Occurred

Check all that apply for items 11 – 17:

11.

I did not author ize anyone t o use m y nam e or per sonal inf or m at ion t o seek the

m oney, cr edit , loans, goods or ser vices des cr ibed in t his r epor t .

12.

I did not r eceive any benef it , m oney, goods or ser vices as a r esul t of t he event s descibed in

t his r epor t .

Name ______ __________ ______ Scottsdale Pol ice Department Report Number ________________________ Page 2

13.

M y ident if icat ion docum ent s ( f or exam ple, cr edit car ds; bir t h cer t if icates; dr iver 's l icense;

Social Secur it y car d; et c. ) w er e:

stolen lost on or about ________________________________

(day/month/year)

14.

To t he best of m y knowledge and bel ief , the f ol low ing per son( s) used m y inf or m at ion ( f or exam pl e, m y

nam e, addr ess, dat e of bir t h, exist ing account num ber s, Social Secur it y num ber , m ot her 's m aiden nam e,

et c.) or ident if icat ion docum ent s t o get m oney, cr edit , loans, goods or s er vices wit hout m y know ledge or

authori zation:

________________________________ ___________________________________

Name (if known) Name (if known)

________________________________ ___________________________________

Address (if known)

________________________________ ___________________________________

Phone number(s) (if known) Phone numbe r(s) (if known)

________________________________ ___________________________________

Additional information Additional information

15.

I do NO T know who used m y inf or m at ion or ident if ication docum ent s to get m oney, cr edit ,

loans, goods or ser vices w it hout m y knowl edge or aut hor izat ion

16.

A

ddit ional com m ent s: ( For exam pl e, descr ipt ion of t he f r aud, which docum ent s or inf or m at ion

were u sed or h ow th e iden tity th eif gain ed access to y ou r in formation )

___________________________________________________________________________

(Attach additional pages as ne cessary.)

Name ______ __________ ______ Scottsdale Pol ice Department Report Number _____________________ Page 3

Victim’s Law Enforcement Actions

17. (check only one)

I am w il ling t o assist in t he pr osecut ion of t he per son( s) who com m it t ed t his f r aud.

I am N OT w il ling t o ass ist in t he pr osecut ion of t he per son( s) who com m it t ed t his f r aud.

18. (check only one)

I am aut hor izing t he r el ease of this inf or m at ion t o l aw enf or cem ent f or the pur poses of as sist ing

t hem in t he invest igat ion and pr osecut ion of t he per son( s) who com m it t ed t his f r aud.

I am N OT aut hor izing t he r el ease of this inf or m at ion t o l aw enf or cem ent f or the pur poses of as sist ing

t hem in t he invest igat ion and pr osecut ion of t he per son( s) who com m it t ed t his f r aud.

19. (check all that apply) I

have have not reported the events d escribed in this affidavit to the police

or other law enforceme nt agency. The police

did did not write a report. In the event you have

contacted the police or other law enforcement agency please com plete the following information:

______________________________________ _________________________________________

(Agenc

y #1) (Officer/Age

ncy personnel taking report)

______________________________________ _________________________________________

(Date of Report) (Report number, if any)

______________________________________ __________________________________________

(Phone number) (email address, if any)

______________________________________ _________________________________________

(Agenc

y #2) (Officer/Age

ncy personnel taking report)

______________________________________ _________________________________________

(Date of Report) (Report number, if any)

______________________________________ __________________________________________

(Phone number) (email address, if any)

Documentation Checklist

Please indicate the supporting documentation you are able to provide to the comp

anies you plan notify.

Attach copies (NOT origin als) to the affidavit before sending it to the compa nie s.

20.

A

copy of a valid gover nm ent - issued phot o- ident if icat ion car d ( f or exam ple, your dr iver 's license, s t at e-

issued ID car d, or your passpor t .) If you ar e under 16 and don't have a phot o- ID, you m ay subm it a copy of

your bir t h cer t if icat e or a copy of your of f icial sc hool r ecor ds showing your enr ol lm ent and pl ace of

residence.

21.

Pr oof of r esidency dur ing t he t im e t he disput ed bil l occur r ed, t he l oan was m ade or t he ot her event t ook pl ace

( f or exam ple, a r ent al /l ease agr eem ent in your nam e, a copy of a ut il it y bil l or a copy of an insur ance bil l.

Name ______ __________ ______ Scottsdale Pol ice Department Report Number ________________________ Page 4

22.

A

copy of the r epor t f il ed wit h t he pol ice or sher if f ' s depar t m ent . If you ar e unabl e t o obtain a r epor t or r epor t

num ber f r om t he pol ice, pl eas e indicat e that in It em 19. Som e com panies onl y need t he r epor t num ber , not a

copy of the r epor t . You m ay want t o check wit h each com pany.

Si

g

nature

I certify that, to the best of my knowledge and beli

e

f, all the information on and attached to this

affidavit is true, correct, and complete and made in good faith. I also understand that this affidavit or the

information it contains may be made available to federal, state, and/or local law enforcement agencies for

such action within their juri sdiction as they deem appropriate. I understand that knowi ngly making any false

or fraudulent statement o r rep re sentatio n to the government may constitute a violation of 18 U.S.C. 1001 or

other federal, state or local criminal statutes, and may result in imposition of a fine or imprisonment or both

______________________________________ _____________________________________

(signature) (date signed)

_______________________________________

(Notary)

[Check with each com pany. Creditors sometim es require nota

r

ization. If they do not, please h ave o ne

witness (non-relative) sign below that you completed and signed this affidavit.]

Witness:

______________________________________ ___________________________________

(signature) (printed name)

______________________________________ ____________________________________

(date) (telephone number)

Name ______ __________ ______ Scottsdale Pol ice 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 notifyin

g 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, att

ach a copy of that docu

ment (NOT the original).

I declare (check all that apply):

As a r esul t of t he event ( s) descr ibed in t he ID Thef t Af f idavit , t he f oll owing account ( s) was/ wer e opened at

your com pany in m y nam e w it hout m y know ledge, per m ission or aut hor izat ion using m y per sonal inf or m at ion

or ident if ying docum ent s:

Creditor

Name/Address

(the company that opened

the account or provided the

goods or services)

Account

Number

Type of unauthorized

Credit/goods/services

Provided by creditor

(

If known)

Date

Issued or

Opened

(if known)

Amount/Value

provided

(the amount charged or

the cost of the

goods/services)

Example

Exampl e National Bank

22 Main Street

Columbus, OH 22722

01234567-89

Auto Loan

01/05/2002

$25,500.00

Dur ing t he t im e of t he accounds descr ibed above, I had t he f ol low ing account open w it h your com pany:

Billing name: ______________________________________ _____________________________

Billing address: ___________________________________________________

______________

Account number: __ ______________________________________________________________

Fillable Printable ID Theft Affidavit - Scottsdale of Arizona

Fillable Printable ID Theft Affidavit - Scottsdale of Arizona

ID Theft Affidavit - Scottsdale of Arizona