This document is an Identity Theft Victim's Complaint and Affidavit form that allows victims to file a report with law enforcement and disputes with credit agencies about identity theft issues. The 3-page form collects information about the victim, the fraud, documentation of the victim's identity, affected accounts and financial information, and includes a section for a law enforcement report. It aims to help victims block identity theft information from credit reports and prove to companies that the victim is not responsible for the fraud.
This document contains an identity theft victim's complaint and affidavit. It collects personal information about the victim such as name, address, phone numbers, and social security number. It documents the fraudulent accounts and activities resulting from the identity theft, including the date opened or misused, amount obtained, and account details. The victim can choose to file a law enforcement report and obtain a case number, or sign the affidavit to prove to companies that they are not responsible for the fraud without filing a report. The victim certifies the information is true and understands making false statements could result in legal penalties.
1) The document is an identity theft statement form for notifying companies of unauthorized activity on accounts.
2) It requests personal information about the victim such as name, address, contact details, as well as details about the identity theft incident and any lost or stolen identification documents.
3) The victim must provide descriptions of any unauthorized accounts opened or existing accounts accessed without permission, including company names, account types and numbers, dates and amounts of fraudulent activity.
This document contains an identity theft victim's complaint and affidavit. It collects personal information about the victim such as name, address, phone numbers, and social security number. It documents the fraudulent accounts and activities, including the dates they occurred and the companies involved. Law enforcement report information is included, such as the filing date, report number, and officer details. The victim signs affidavits certifying the information is true and authorizing the report to be shared with law enforcement.
The document is an accident injury claim form that must be completed in its entirety for a claim to be processed. It requests information about the date and location of the accident, how it happened, and whether the patient was treated more than 50 miles from their residence. It also includes sections for patient and policyholder information to be filled out, as well as a physician's statement regarding the incident and treatment.
This document is an application for a loan from the Community Futures lending program. It includes information about the applicant's business and personal financial details. The business is seeking a loan of an undisclosed amount for unspecified purposes. The applicant provides information such as ownership percentages, years in business, number of employees, personal income statements, statements of assets and liabilities, and declarations to assess loan eligibility.
All product and company names mentioned herein are for identification and educational purposes only and are the property of, and may be trademarks of, their respective owners.
This document is a reporting form from the Montana Department of Justice Gambling Control Division and Department of Revenue Liquor Control Division. It requires licensees and applicants to report any noninstitutional loans, financing, or transfers of security interests over $30,000. The form collects information about the source of funds, terms of the loan, and authorization to perform background checks on noninstitutional lenders. It aims to ensure funding sources do not involve unsuitable parties or violate gambling and liquor laws.
This document is a request form for a contractor to obtain installation access to Joint Base Myer-Henderson Hall. It contains sections for the contractor to provide personal identifying information and consent to a criminal background check. The sponsor, a government employee, must certify that the contractor requires access to perform assigned duties. Completed forms are used to screen applicants and identify any criminal histories that could prevent installation access.
This document contains an identity theft victim's complaint and affidavit. It collects personal information about the victim such as name, address, phone numbers, and social security number. It documents the fraudulent accounts and activities resulting from the identity theft, including the date opened or misused, amount obtained, and account details. The victim can choose to file a law enforcement report and obtain a case number, or sign the affidavit to prove to companies that they are not responsible for the fraud without filing a report. The victim certifies the information is true and understands making false statements could result in legal penalties.
1) The document is an identity theft statement form for notifying companies of unauthorized activity on accounts.
2) It requests personal information about the victim such as name, address, contact details, as well as details about the identity theft incident and any lost or stolen identification documents.
3) The victim must provide descriptions of any unauthorized accounts opened or existing accounts accessed without permission, including company names, account types and numbers, dates and amounts of fraudulent activity.
This document contains an identity theft victim's complaint and affidavit. It collects personal information about the victim such as name, address, phone numbers, and social security number. It documents the fraudulent accounts and activities, including the dates they occurred and the companies involved. Law enforcement report information is included, such as the filing date, report number, and officer details. The victim signs affidavits certifying the information is true and authorizing the report to be shared with law enforcement.
The document is an accident injury claim form that must be completed in its entirety for a claim to be processed. It requests information about the date and location of the accident, how it happened, and whether the patient was treated more than 50 miles from their residence. It also includes sections for patient and policyholder information to be filled out, as well as a physician's statement regarding the incident and treatment.
This document is an application for a loan from the Community Futures lending program. It includes information about the applicant's business and personal financial details. The business is seeking a loan of an undisclosed amount for unspecified purposes. The applicant provides information such as ownership percentages, years in business, number of employees, personal income statements, statements of assets and liabilities, and declarations to assess loan eligibility.
All product and company names mentioned herein are for identification and educational purposes only and are the property of, and may be trademarks of, their respective owners.
This document is a reporting form from the Montana Department of Justice Gambling Control Division and Department of Revenue Liquor Control Division. It requires licensees and applicants to report any noninstitutional loans, financing, or transfers of security interests over $30,000. The form collects information about the source of funds, terms of the loan, and authorization to perform background checks on noninstitutional lenders. It aims to ensure funding sources do not involve unsuitable parties or violate gambling and liquor laws.
This document is a request form for a contractor to obtain installation access to Joint Base Myer-Henderson Hall. It contains sections for the contractor to provide personal identifying information and consent to a criminal background check. The sponsor, a government employee, must certify that the contractor requires access to perform assigned duties. Completed forms are used to screen applicants and identify any criminal histories that could prevent installation access.
The document discusses how to dispute errors on your credit report. It provides the following key points:
1) You have the right to receive one free copy of your credit report each year from each of the three major credit reporting agencies (Experian, Equifax, and TransUnion) to check for any inaccuracies.
2) If you find errors, you should submit dispute letters to the credit reporting agency and the provider of the inaccurate information, including documentation of the correct information.
3) The credit reporting agency and information provider must investigate disputes and correct or delete inaccurate information, notifying others who received the report of corrections.
This claim form is used to claim losses caused by a tenant, including property damage and loss of rent. The form collects policy and contact details, rental payment history, expenses, damage details if applicable, and a declaration. It aims to provide insurers with the necessary information to process tenant-related claims promptly and fairly. Repairs should be commenced within 7 days and costs like general cleaning are not claimable. The form must be fully completed for claims to be processed.
This document contains an identity theft affidavit and complaint form completed by Adalberto Cervantes Rodriguez. It includes his personal information, details about fraudulent accounts and inquiries he believes were opened using his identity, and sections to file a police report or have his affidavit witnessed. The form provides a way for identity theft victims to document the crime and disputes with creditors for the purpose of removing fraudulent information from their credit reports.
The document is a complaint form for the California Department of Corporations. It provides information about what types of complaints the Department can handle related to securities professionals, finance lenders, bill payers, mortgage lenders and escrow agents. It instructs complainants to summarize the key details of the complaint including who was involved, what happened, when and where. It also requests contact information and supporting documents to assist with investigating and resolving the complaint.
ID Theft: What You Need to Know - Juliana HarrisIT-oLogy
The South Carolina Department of Consumer Affairs (SCDCA) has 6 divisions that work to resolve consumer complaints, regulate industries, educate the public, and combat identity theft. The SCDCA receives hundreds of consumer complaints each month and resolves about 85% satisfactorily. It also oversees regulatory programs, represents consumers in legal cases, conducts investigations, and disseminates consumer information through various channels including social media. Identity theft remains a major problem, but the SCDCA provides resources to help citizens monitor their credit, place freezes and fraud alerts on reports, and take other protective measures.
This document summarizes an application for employment. It contains sections for general information about the applicant, the position being applied for, education and training history, work experience, and a signature agreeing to the information provided. The applicant is providing all necessary details for a potential employer to evaluate their application.
All product and company names mentioned herein are for identification and educational purposes only and are the property of, and may be trademarks of, their respective owners.
The document appears to be a rental application for a property, as it requests information such as contact details, income sources, rental history, credit history, and references from the applicant. It notes a credit check fee and requires the applicant to sign, agreeing the information provided is accurate and authorizing background checks and verification of references. The level of detail requested in the application suggests it is for a rent-to-own home rental.
The applicant is applying for tenancy and provides personal information such as name, date of birth, social security number, present and previous addresses, employment information, income sources, assets, liabilities, and emergency contact. The applicant authorizes a consumer report and investigation into their background and releases all parties from liability. The applicant certifies the information is true and authorizes disclosure to the property owner or manager.
This document is an application for a Homestead Tax Credit in Maryland. It provides instructions for homeowners to apply for the tax credit on their primary residence by filling out sections with their contact and property details. It notes that only one residence can be claimed as the primary home for tax purposes. Applicants must answer questions about using the property as their primary address and provide social security numbers for all owners to verify residency requirements are met.
1) The document provides instructions for homeowners to complete a packet to request a short sale from Chase, including required documentation from the homeowner, real estate agent, and authorization forms.
2) It lists the required documentation checklist for homeowners, including pay stubs, bank statements, tax returns, and other financial documents.
3) It provides a form for homeowners to authorize Chase to share their mortgage information with third parties like real estate agents or attorneys involved in the short sale process.
The document is a credit application and agreement form for a company seeking a line of credit, which requires the applicant to provide contact and financial information as well as terms for payment and collection. It also includes a personal guaranty that must be signed by partners, officers, or managers to induce the extension of credit and guarantee prompt payment of any debts.
This document provides information about building a better credit report. It discusses rights under the Fair Credit Reporting Act and Fair and Accurate Credit Transactions Act. It explains how to legally improve an inaccurate credit report by disputing errors with credit reporting companies and furnishing businesses. It also provides tips on dealing with debt and avoiding credit scams.
This document is a credit application that collects company and contact information, equipment details, references, and authorizes a credit check. It requests the company name, address, tax ID, nature of business, contact names, addresses, phone numbers, and social security numbers of principals. It also asks for equipment details like cost, description, and lease terms. References from banks and trade are solicited. The applicant certifies the credit is for business purposes and authorizes the release of credit information and sharing of reports.
The document discusses identity theft, including how to protect yourself from identity theft and what to do if you become a victim. Some key points:
- Identity theft is a growing problem, affecting over 12% of people in a 2002 survey.
- To protect yourself, shred documents with personal information before throwing them out, use a locked mailbox, and regularly check your credit reports.
- If you become a victim, promptly report the fraud to law enforcement and credit bureaus, place a fraud alert and security freeze on your credit reports, and file an identity theft affidavit.
- Useful resources for information and assistance with identity theft include the Privacy Rights Clearinghouse, Identity Theft Resource Center, and your state Attorney General
The document discusses identity theft and provides tips to protect personal information. It notes that identity theft affects millions of people each year. The document outlines steps to take if identity theft occurs, including filing a report with law enforcement and credit bureaus, and placing a fraud alert or security freeze on credit reports. Useful resources for information on identity theft are also presented, such as the Privacy Rights Clearinghouse, Identity Theft Resource Center, and AnnualCreditReport.com for free credit checks.
The document is a request form for a visitor pass to access Joint Base Myer-Henderson Hall (JBM-HH). It collects personal information such as name, date of birth, citizenship status, and contact details to conduct background checks. Applicants must provide their social security number and consent to criminal records searches. The form also requires information about the applicant's sponsor on the base and justification for access. Completed forms are used to screen applicants and identify anyone who may be ineligible to access the base.
1) This document is a request form for a visitor pass to access Joint Base Myer-Henderson Hall (JBM-HH). It collects personal information such as name, date of birth, citizenship status, and contact details to conduct background checks.
2) The form notifies applicants that providing information is voluntary but required for access. It will be used to screen for criminal histories and conduct records checks through various law enforcement databases.
3) The sponsor certifies that the applicant requires access for official duties or business and warrants a visitor pass according to JBM-HH regulations. The issuing official will then approve or disapprove the request after reviewing the results of background checks.
The document is a technical direction letter from the Army Contracting Command - New Jersey to Advanced Technology International regarding a project agreement with Pfizer for COVID-19 vaccine manufacturing. It directs ATI to issue a firm-fixed price project agreement to Pfizer not to exceed $1,950,097,500 to manufacture 100 million doses of their mRNA-based COVID-19 vaccine. The total project value was determined to be fair and reasonable. Pfizer was selected based on an acceptable proposal and ability to meet requirements. The agreement supports the goal of accelerating and securing US access to a promising COVID-19 vaccine through domestic manufacturing.
The document discusses how to dispute errors on your credit report. It provides the following key points:
1) You have the right to receive one free copy of your credit report each year from each of the three major credit reporting agencies (Experian, Equifax, and TransUnion) to check for any inaccuracies.
2) If you find errors, you should submit dispute letters to the credit reporting agency and the provider of the inaccurate information, including documentation of the correct information.
3) The credit reporting agency and information provider must investigate disputes and correct or delete inaccurate information, notifying others who received the report of corrections.
This claim form is used to claim losses caused by a tenant, including property damage and loss of rent. The form collects policy and contact details, rental payment history, expenses, damage details if applicable, and a declaration. It aims to provide insurers with the necessary information to process tenant-related claims promptly and fairly. Repairs should be commenced within 7 days and costs like general cleaning are not claimable. The form must be fully completed for claims to be processed.
This document contains an identity theft affidavit and complaint form completed by Adalberto Cervantes Rodriguez. It includes his personal information, details about fraudulent accounts and inquiries he believes were opened using his identity, and sections to file a police report or have his affidavit witnessed. The form provides a way for identity theft victims to document the crime and disputes with creditors for the purpose of removing fraudulent information from their credit reports.
The document is a complaint form for the California Department of Corporations. It provides information about what types of complaints the Department can handle related to securities professionals, finance lenders, bill payers, mortgage lenders and escrow agents. It instructs complainants to summarize the key details of the complaint including who was involved, what happened, when and where. It also requests contact information and supporting documents to assist with investigating and resolving the complaint.
ID Theft: What You Need to Know - Juliana HarrisIT-oLogy
The South Carolina Department of Consumer Affairs (SCDCA) has 6 divisions that work to resolve consumer complaints, regulate industries, educate the public, and combat identity theft. The SCDCA receives hundreds of consumer complaints each month and resolves about 85% satisfactorily. It also oversees regulatory programs, represents consumers in legal cases, conducts investigations, and disseminates consumer information through various channels including social media. Identity theft remains a major problem, but the SCDCA provides resources to help citizens monitor their credit, place freezes and fraud alerts on reports, and take other protective measures.
This document summarizes an application for employment. It contains sections for general information about the applicant, the position being applied for, education and training history, work experience, and a signature agreeing to the information provided. The applicant is providing all necessary details for a potential employer to evaluate their application.
All product and company names mentioned herein are for identification and educational purposes only and are the property of, and may be trademarks of, their respective owners.
The document appears to be a rental application for a property, as it requests information such as contact details, income sources, rental history, credit history, and references from the applicant. It notes a credit check fee and requires the applicant to sign, agreeing the information provided is accurate and authorizing background checks and verification of references. The level of detail requested in the application suggests it is for a rent-to-own home rental.
The applicant is applying for tenancy and provides personal information such as name, date of birth, social security number, present and previous addresses, employment information, income sources, assets, liabilities, and emergency contact. The applicant authorizes a consumer report and investigation into their background and releases all parties from liability. The applicant certifies the information is true and authorizes disclosure to the property owner or manager.
This document is an application for a Homestead Tax Credit in Maryland. It provides instructions for homeowners to apply for the tax credit on their primary residence by filling out sections with their contact and property details. It notes that only one residence can be claimed as the primary home for tax purposes. Applicants must answer questions about using the property as their primary address and provide social security numbers for all owners to verify residency requirements are met.
1) The document provides instructions for homeowners to complete a packet to request a short sale from Chase, including required documentation from the homeowner, real estate agent, and authorization forms.
2) It lists the required documentation checklist for homeowners, including pay stubs, bank statements, tax returns, and other financial documents.
3) It provides a form for homeowners to authorize Chase to share their mortgage information with third parties like real estate agents or attorneys involved in the short sale process.
The document is a credit application and agreement form for a company seeking a line of credit, which requires the applicant to provide contact and financial information as well as terms for payment and collection. It also includes a personal guaranty that must be signed by partners, officers, or managers to induce the extension of credit and guarantee prompt payment of any debts.
This document provides information about building a better credit report. It discusses rights under the Fair Credit Reporting Act and Fair and Accurate Credit Transactions Act. It explains how to legally improve an inaccurate credit report by disputing errors with credit reporting companies and furnishing businesses. It also provides tips on dealing with debt and avoiding credit scams.
This document is a credit application that collects company and contact information, equipment details, references, and authorizes a credit check. It requests the company name, address, tax ID, nature of business, contact names, addresses, phone numbers, and social security numbers of principals. It also asks for equipment details like cost, description, and lease terms. References from banks and trade are solicited. The applicant certifies the credit is for business purposes and authorizes the release of credit information and sharing of reports.
The document discusses identity theft, including how to protect yourself from identity theft and what to do if you become a victim. Some key points:
- Identity theft is a growing problem, affecting over 12% of people in a 2002 survey.
- To protect yourself, shred documents with personal information before throwing them out, use a locked mailbox, and regularly check your credit reports.
- If you become a victim, promptly report the fraud to law enforcement and credit bureaus, place a fraud alert and security freeze on your credit reports, and file an identity theft affidavit.
- Useful resources for information and assistance with identity theft include the Privacy Rights Clearinghouse, Identity Theft Resource Center, and your state Attorney General
The document discusses identity theft and provides tips to protect personal information. It notes that identity theft affects millions of people each year. The document outlines steps to take if identity theft occurs, including filing a report with law enforcement and credit bureaus, and placing a fraud alert or security freeze on credit reports. Useful resources for information on identity theft are also presented, such as the Privacy Rights Clearinghouse, Identity Theft Resource Center, and AnnualCreditReport.com for free credit checks.
The document is a request form for a visitor pass to access Joint Base Myer-Henderson Hall (JBM-HH). It collects personal information such as name, date of birth, citizenship status, and contact details to conduct background checks. Applicants must provide their social security number and consent to criminal records searches. The form also requires information about the applicant's sponsor on the base and justification for access. Completed forms are used to screen applicants and identify anyone who may be ineligible to access the base.
1) This document is a request form for a visitor pass to access Joint Base Myer-Henderson Hall (JBM-HH). It collects personal information such as name, date of birth, citizenship status, and contact details to conduct background checks.
2) The form notifies applicants that providing information is voluntary but required for access. It will be used to screen for criminal histories and conduct records checks through various law enforcement databases.
3) The sponsor certifies that the applicant requires access for official duties or business and warrants a visitor pass according to JBM-HH regulations. The issuing official will then approve or disapprove the request after reviewing the results of background checks.
The document is a technical direction letter from the Army Contracting Command - New Jersey to Advanced Technology International regarding a project agreement with Pfizer for COVID-19 vaccine manufacturing. It directs ATI to issue a firm-fixed price project agreement to Pfizer not to exceed $1,950,097,500 to manufacture 100 million doses of their mRNA-based COVID-19 vaccine. The total project value was determined to be fair and reasonable. Pfizer was selected based on an acceptable proposal and ability to meet requirements. The agreement supports the goal of accelerating and securing US access to a promising COVID-19 vaccine through domestic manufacturing.
After announcing they would kill me "this time for real",
- Day 1 my Google Voice number that I use for 2FA got deleted
- Day 2 I got fake-evicted via someone who doesn't own the house and two fake Sheriffs
- Day 3 my debit card gets disabled as an announced "revenge" for reporting Skype fraud
Day 4 my bank account gets closed
Day 5 I learn about the continuation of a fake court case.
While my rent is prepaid for the whole year, to the real landlord, and the court hearing was in-person (but I still clicked on the Zoom link, and nobody was there), they claim I didn't show up for the court date - for a case that does not exist.
This document is an email report from Intelius containing personal information about Richard A Balman such as known aliases, birth information, potential imposters, employment history, education, phone numbers, emails, addresses, and social media profiles. It includes a disclaimer stating that Intelius is not a consumer reporting agency under the Fair Credit Reporting Act.
This document provides information about fraud alerts from Intelius. It states that Intelius is not a consumer reporting agency under the Fair Credit Reporting Act. It lists restrictions on using information from Intelius reports for determining eligibility for insurance, credit, employment, education, housing, or other benefits. The disclaimer notes that information was not collected for furnishing consumer reports. It warns against using Intelius data to take adverse actions as defined by the FCRA.
Julie A Vaillancourt-aka J Motel aka Paris Ivy aka yourwetdreamsAurorasa Coaching
This background report provides personal and public records information for Julie A Vaillancourt. It includes her known aliases, birthdate, relatives, possible associates, addresses, phone numbers, employment history, and currently owned property. The report did not uncover any criminal, traffic, license, bankruptcy, or asset ownership other than the currently owned property.
This email report provides personal information, contact information, location information, and social profiles for an individual named Sandra Harper. The report lists possible aliases, birth information, phone numbers, email addresses, current and previous addresses, online profiles, and articles related to the individual. It is accompanied by a disclaimer stating that the information is not a consumer report under the Fair Credit Reporting Act.
This background report provides personal information about Timothy Edward Petri, including known aliases, birth information, possible relatives and associates, phone numbers, email addresses, current and previous addresses, and possible neighbors. The report was created on June 11, 2023 by Intelius and includes a disclaimer about not being a consumer reporting agency under the Fair Credit Reporting Act.
This background report provides a disclaimer stating that Intelius is not a consumer reporting agency under the Fair Credit Reporting Act and the protections it provides do not apply. The information in the report cannot be used to determine suitability for health insurance, credit/loans, employment, education, housing, or benefits. The data was not collected for furnishing consumer reports and cannot be used as a factor in establishing personal credit, loans, insurance risks, employment decisions, educational opportunities, licenses, or other transactions covered by the FCRA.
Dennis N Gorelik - New World Order Illuminati at SkypeAurorasa Coaching
Suspected pedophile who stole money from Microsoft for many years.
Skype is out of business. They cannot issue new numbers, and the current numbers will be released shortly, and customer receive their payments back.
In exchange for the inconvenience, they can sign up with a safe provider.
This is a gang stalker organization, no matter as what it began.
Dennis N. Gorelik currently lives at 46 Dancer Pl in Ponte Vedra, FL. He has lived at several addresses in Florida and other states over the years. No criminal, arrest, warrant, inmate, bankruptcy or judgment records were found for Gorelik. The background report provides his address history, contact information, and information about his current home which he owns jointly with his wife Natalia Gorelik, valued at $304,643.
I just received a spoofed email from Skype, and discovered someone had put the darkweb Google Gmail mailhahaha8@gmail.com (that they took and locked me out about 8(!) years ago (for hard-bouncing their spam via forwarding to Zoho) is ON MY XBOX@aurorasa.com account.
Nearly stalked to death, Patrica had her house stolen by the New World Order gang stalkers, and lived in a mental facility since 2017.
She's back with her husband now, in her house.
Capital Punishment by Saif Javed (LLM)ppt.pptxOmGod1
This PowerPoint presentation, titled "Capital Punishment in India: Constitutionality and Rarest of Rare Principle," is a comprehensive exploration of the death penalty within the Indian criminal justice system. Authored by Saif Javed, an LL.M student specializing in Criminal Law and Criminology at Kazi Nazrul University, the presentation delves into the constitutional aspects and ethical debates surrounding capital punishment. It examines key legal provisions, significant case laws, and the specific categories of offenders excluded from the death penalty. The presentation also discusses recent recommendations by the Law Commission of India regarding the gradual abolishment of capital punishment, except for terrorism-related offenses. This detailed analysis aims to foster informed discussions on the future of the death penalty in India.
A Critical Study of ICC Prosecutor's Move on GAZA WarNilendra Kumar
ICC Prosecutor Karim Khan's proposal to its judges seeking permission to prosecute Israeli leaders and Hamas commanders for crimes against the law of war has serious ramifications and calls deep scrutiny.
Indonesian Manpower Regulation on Severance Pay for Retiring Private Sector E...AHRP Law Firm
Law Number 13 of 2003 on Manpower has been partially revoked and amended several times, with the latest amendment made through Law Number 6 of 2023. Attention is drawn to a specific part of the Manpower Law concerning severance pay. This aspect is undoubtedly one of the most crucial parts regulated by the Manpower Law. It is essential for both employers and employees to abide by the law, fulfill their obligations, and retain their rights regarding this matter.
1. 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
2. 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
3. _
____________
____________
____________
_______________
_
___
___
___
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_
_______________________________________________________________
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
4. 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.
AmountObtained:
For instance,
the total amount
purchased with
the card or
withdrawn from
the account.
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5. ____________________________________________________________________
____________________________ _____________________
____________________________________________________________________
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): ________________________
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6. _______________________________________ _________________________________________
___
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
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