Section 114 Identity Theft Affidavit

• Library: Consumer Law and Practice 2010 – Forms

The following form is available at:

www.ftc.gov/bcp/edu/resources/forms/affidavit.pdf

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/idtheftto 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 ___ | Leave (3) |
                | (2) My date of birth: __________ (mm/dd/yyyy) | blank until |
                | (3) My Social Security number: ____ - ____ - ____ | you provide |
                | (4) My driver's license: State _____ Number_____ | this form to |
                | (5) My current street address: | someone with |
                | Number & Street Name____________ Apartment, Suite, etc.________ | a legitimate |
                | ____City ___________State___________Zip Code Country_________ | business need, |
                | (6) I have lived at this address since _______(mm/yyyy) | like when you |
                | (7) My daytime phone: (___) __________ | are filing your |
                | My evening phone: (___) __________ | report at the |
                | My email: ____________________ | police station |
                | | or sending |
                | | the form |
                | | to a credit |
                | | reporting |
                | | agency to |
                | | correct your |
                | | credit report. |
                +-----------------------------------------------------------------+------------------+
                

+-----------------------------------------------------------------+------------------+
                | At the Time of the Fraud | |
                +-----------------------------------------------------------------+------------------+
                | (8) My full legal name was: First ___Middle ____Last Suffix ___ | Skip (8) - (10) |
                | (9) My address was: Number & Street Name__________ | if your |
                | Apartment, Suite, etc. __________ | information |
                | City________State ______Zip Code Country______ | has not |
                | (10) My daytime phone: (___) __________ | changed since |
                | My evening phone: (___) __________ | the fraud. |
                | 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.

+-------------------------------------------------------------------------------------------+
                | About You (the victim) (Continued) |
                +-------------------------------------------------------------------------------------------+
                | 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. |

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