Fillable Printable Identity Theft Affidavit Form - Texas

Identity Theft Affidavit Form - Texas

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