TAILIEUCHUNG - Identity Theft Victim’s Complaint and Affidavit

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. | 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 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 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 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. 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. Skip 8 - 10 if your information has not changed since the fraud. 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. Victim s Name Phone number Page 2 About You the victim Continued Declarations 11 I did OR did not authorize anyone to use my name or personal

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