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Fillable Printable Identity Theft Affidavit Form - Texas

Fillable Printable Identity Theft Affidavit Form - Texas

Identity Theft Affidavit Form - Texas

Identity Theft Affidavit Form - Texas

F I G H T I N G
F I G H T I N G
www.oag.state.tx.us
Federal Trade Commission
Identity Theft Afdavit
F I G H T I N G
To make certain that you do not become responsible for any debts incurred
by an identity thief, you must prove to each of the companies where
accounts were opened or used in your name that you didn’t create the
debt. A group of credit grantors, consumer advocates, and attorneys at
the Federal Trade Commission(FTC) developed an ID Theft Afdavit to make
it easier for fraud victims to report information. While many companies
accept this afdavit, others require that you submit more or different
forms. Before you send the afdavit, contact each company to nd out if
they accept it. It will be necessary to provide the information in this
afdavit anywhere a new account was opened in your name. The informa-
tion will enable the companies to investigate the fraud and decide the out-
come of your claim. If someone made unauthorized charges to an existing
account, call the company for instructions. This afdavit has two parts:
Part One — the ID Theft Afdavit — is where you report general informa-
tion about yourself and the theft.
Part Two — the Fraudulent Account Statement — is where you describe
the fraudulent account(s) opened in your name.
Use a separate Fraudulent Account Statement for each company you need
to write to. When you send the afdavit to the companies, attach copies
(NOT originals) of any supporting documents (for example, driver’s license
or police report). Before submitting your afdavit, review the disputed
account(s) with family members or friends who may have information about
the account(s) or access to them. Complete this afdavit as soon as pos-
sible. Many creditors ask that you send it within two weeks. Delays on your
part could slow the investigation.
ID Theft Victim’s Kit
page 17
Instructions: Completing the ID Theft
Afdavit
Be as accurate and complete as possible. You may choose not to provide
some of the information requested. However, incorrect or incomplete
information will slow the process of investigating your claim and absolving
the debt. Print clearly. When you have nished completing the afdavit,
mail a copy to each creditor, bank, or company that provided the thief
with the unauthorized credit, goods, or services you describe.
Attach a copy of the Fraudulent Account Statement with information only
on accounts opened at the institution to which you are sending the packet,
as well as any other supporting documentation you are able to provide.
Send the appropriate documents to each company by certied mail, return
receipt requested, so you can prove that it was received.
The companies will review your claim and send you a written response
telling you the outcome of their investigation.
Keep a copy of everything you submit.
If you are unable to complete the afdavit, a legal guardian or
someone with power of attorney may complete it for you.
Except as noted, the information you provide will be used only by the
company to process your afdavit, investigate the events you report, and
help stop further fraud.
If this afdavit is requested in a lawsuit, the company might have to
provide it to the requesting party.
Completing this afdavit does not guarantee that the identity thief will be
prosecuted or that the debt will be cleared.
DO NOT SEND AFFIDAVIT TO THE FTC
OR ANY OTHER GOVERNMENT AGENCY
ID Theft Victim’s Kit
page 18
If you haven’t already done so, report the fraud to the following
organizations:
1. Any one of the nationwide consumer reporting companies to place a
fraud alert on your credit report. Fraud alerts can help prevent an identity
thief from opening any more accounts in your name. The company you
call is required to contact the other two, which will place an alert on their
versions of your report, too.
• Equifax: 1-800-525-6285;
www.equifax.com
• Experian: 1-888-EXPERIAN (397-3742);
www.experian.com
TransUnion: 1-800-680-7289;
www.transunion.com
In addition to placing the fraud alert, the three consumer reporting compa-
nies will send you free copies of your credit reports, and, if you ask, they
will display only the last four digits of your Social Security number on
your credit reports.
2. The security or fraud department of each company where you know, or
believe, accounts have been tampered with or opened fraudulently. Close
the accounts. Follow up in writing, and include copies (NOT originals)
of supporting documents. It’s important to notify credit card companies
and banks in writing. Send your letters by certied mail, return receipt
requested, so you can document what the company received and when.
Keep a le of your correspondence and enclosures. When you open new
accounts, use new Personal Identication Numbers (PINs) and passwords.
Avoid using easily available information like your mother’s maiden name,
your birth date, the last four digits of your Social Security number or your
phone number, or a series of consecutive numbers.
ID Theft Victim’s Kit
page 19
3. Your local police or the police in the community where the identity
theft took place to le a report. Get a copy of the police report or, at the
very least, the number of the report. It can help you deal with creditors
who need proof of the crime. If the police are reluctant to take your
report, ask to le a “Miscellaneous Incidents” report, or try another
jurisdiction, like your state police. You also can check with your state
Attorney General’s ofce to nd out if state law requires the police to
take reports for identity theft. Check the Blue Pages of your telephone
directory for the phone number or check www.naag.org for a list of state
Attorneys General.
4. The Federal Trade Commission. By sharing your identity theft complaint
with the FTC, you will provide important information that can help law
enforcement ofcials across the nation track down identity thieves and
stop them. The FTC also can refer victims’ complaints to other govern-
ment agencies and companies for further action, as well as investigate
companies for violations of laws that the FTC enforces.
You can le a complaint online at www.consumer.gov/idtheft.
If you don’t have Internet access, call the FTC’s Identity Theft Hotline,
toll-free: 1-877-IDTHEFT (438-4338); TTY: 1-866-653-4261; or write:
Identity Theft Clearinghouse, Federal Trade
Commission, 600 Pennsylvania Avenue,
NW, Washington, DC 20580.
DO NOT SEND AFFIDAVIT TO THE FTC
OR ANY OTHER GOVERNMENT AGENCY
ID Theft Victim’s Kit
page 20
Victim Information
(1) My full legal name is ___________________________________________________________
(First) (Middle) (Last) (Jr., Sr., III)
(2) (If different from above) When the events described in this affidavit took place, I was known as
____________________________________________________________________________
(First) (Middle) (Last) (Jr., Sr., III)
(3) My date of birth is ____________________
(day/month/year)
(4) My Social Security number is________________________________
(5) My driver’s license or identification card state and 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 described in this affidavit took place, 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 (____)____________________
ID Theft Affidavit
Name __________________________________ Phone number _______________________ Page 1
DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER
GOVERNMENT AGENCY
Name __________________________________ Phone number _______________________ Page 2
DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER
GOVERNMENT AGENCY
How the Fraud Occurred
Check all that apply for items 11 - 17:
(11) 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.
(12) I did not receive any benefit, money, goods or services as a result of the events described
in this report.
(13) My identification documents (for example, credit cards; birth certificate; driver’s license;
Social Security card; etc.) were stolen lost on or about __________________.
(day/month/year)
(14) To the best of my knowledge and belief, 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 get money, credit,
loans, goods or services without my knowledge or authorization:
_________________________________ ____________________________________
Name (if known) Name (if known)
_________________________________ ____________________________________
Address (if known) Address (if known)
_______________________________ ____________________________________
Phone number(s) (if known) Phone number(s) (if known)
_________________________________ ____________________________________
Additional information (if known) Additional information (if known)
(15) I do NOT know who used my information or identification documents to get money,
credit, loans, goods or services without my knowledge or authorization.
(16) Additional comments: (For example, description of the fraud, which documents or
information were used or how the identity thief gained access to your information.)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
(Attach additional pages as necessary.)
Name __________________________________ Phone number _______________________ Page 3
DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER
GOVERNMENT AGENCY
Victim’s Law Enforcement Actions
(17) (check one) I am am not willing to assist in the prosecution of the person(s) who
committed this fraud.
(18) (check one) I am am not authorizing the release of this information to law
enforcement for the purpose of assisting them in the investigation and prosecution of the
person(s) who committed this fraud.
(19) (check all that apply) I have have not reported the events described in this affidavit
to the police or other law enforcement agency. The police did did not write a
report. In the event you have contacted the police or other law enforcement agency, please
complete the following:
_____________________________ _________________________________
(Agency #1) (Officer/Agency personnel taking report)
____________________________ _________________________________
(Date of report) (Report number, if any)
_____________________________ _________________________________
(Phone number) (email address, if any)
_____________________________ _________________________________
(Agency #2) (Officer/Agency 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 companies you plan to
notify. Attach copies (NOT originals) to the affidavit before sending it to the companies.
(20) A copy of a valid government-issued photo-identification card (for example, your driver’s
license, state-issued ID card or your passport). If you are under 16 and don’t have a
photo-ID, you may submit a copy of your birth certificate or a copy of your official school
records showing your enrollment and place of residence.
(21) Proof of residency during the time the disputed bill occurred, the loan was made or the
other event took place (for example, a rental/lease agreement in your name, a copy of a
utility bill or a copy of an insurance bill).
(22) A copy of the report you filed with the police or sheriff’s department. If you are unable to
obtain a report or report number from the police, please indicate that in Item 19. Some
companies only need the report number, not a copy of the report. You may want to check
with each company.
Signature
I certify that, to the best of my knowledge and belief, all the information on and attached to this
affidavit is true, correct, and complete and made in good faith. I also understand that is affidavit 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 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 company. Creditors sometimes require notarization. If they do not, please have one
witness (non-relative) sign below that you completed and signed this affidavit.]
Witness:
_______________________________________ __________________________________
(signature) (printed name)
_______________________________________ __________________________________
(date) (telephone number)
Name __________________________________ Phone number _______________________ Page 4
DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER
GOVERNMENT AGENCY
I declare (check all that apply):
As a result of the event(s) described in the ID Theft Affidavit, the following account(s) was/were
opened at your company in my name without my knowledge, permission or authorization using
my personal information or identifying documents:
Completing this Statement
Make as many copies of this page as you need. Complete a separate page for each
company you’re notifying 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,
attach a copy of that document (NOT the original).
Fraudulent Account Statement
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)
During the time of the accounts described above, I had the following account open with your company:
Billing name ___________________________________________________________________
Billing address__________________________________________________________________
Account number _______________________________________________________________
Example
Example National Bank
22 Main Street
Columbus, Ohio 22722
01234567-89 auto loan 01/05/2002 $25,500.00
Name __________________________________ Phone number _______________________ Page 5
DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER
GOVERNMENT AGENCY
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