Fillable Printable Identity Theft Affidavit - California
Fillable Printable Identity Theft Affidavit - California
Identity Theft Affidavit - California
Average time to complete: 10 minutes
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.
About You (the victim)
Now
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.
(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
Skip (8) - (10)
if your
information
has not
changed since
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
(10) My daytime phone: (____)_________________ My evening phone: (____)_________________
My email: _____________________________________
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.
H-1
Victim’s Name _______________________________ Phone number (____)_________________
About You (the victim) (Continued)
Page 2
Declarations
(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.
About the Fraud
(14):
Enter what
you know
about anyone
you believe
was involved
(even if you
don’t have
complete
information).
(14) I believe the following person used my information or identification
documents to open new accounts, use my existing accounts, or commit other
fraud.
Name: ___________________________________________________
First Middle Last Suffix
Address: __________________________________________________
Number & Street Name Apartment, Suite, etc.
__________________________________________________________
City State Zip Code Country
Phone Numbers: (____)_______________ (____)________________
Additional information about this person: _____________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
H-2
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____________
____________
____________
_______________
_
___
___
___
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_ _______________________________________________________________
Victim’s Name _______________________________ Phone number (____)________________
(15) Additional information about the crime (for example, how the identity thief
gained access to your information or which documents or information were
used):
_______________________________________________________________
_ Page 3
(14) and (15):
Attach
additional
sheets as
needed.
Documentation
(16) I can verify my identity with these documents:
(16): Reminder:
Attach copies
of your identity
documents
when sending
this form to
creditors
and credit
reporting
agencies.
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).
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: _______________________________________________________________
Company Name: _______________________________________________________________
Company Name: _______________________________________________________________
H-3
Victim’s Name _______________________________ Phone number (____)_________________ Page 4
(19) Below are details about the different frauds committed using my personal information.
___________________________________________________________________
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 ($)
(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-4
____________________________________________________________________
____________________________ _____________________
____________________________________________________________________
Victim’s Name _______________________________ Phone number (____)_________________ Page 5
Your Law Enforcement Report
(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
(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.
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): ________________________
H-5
_______________________________________ _________________________________________
___
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.
______________ Page 6 Victim’s Name _______________________________ Phone number (____)
Signature
Signature Date Signed (mm/dd/yyyy)
Your Affidavit
(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
H-6
