Affidavit of Identity Theft - Template, Sample Form Pro · US-law

AFFIDAVIT OF IDENTITY THEFT

(Declaration Pursuant to 28 U.S.C. § 1746 and Applicable State Law)

STATE OF ________

COUNTY OF ________

I, ________, being first duly sworn, depose and state as follows:

§ 1. VICTIM INFORMATION

1. My full legal name is ________, and I was born on ________.
2. The last four digits of my Social Security Number are ________.
3. My driver's license or state-issued identification number is ________, issued by the State of ________.
4. I have resided at the following address since ________:

________

5. My prior address, if I have resided at my current address for less than two (2) years, is:

________

6. The best way to contact me is as follows (telephone, email, and/or mailing address):

________

§ 2. DESCRIPTION OF THE IDENTITY THEFT

7. I did not authorize anyone to use my name or personal information to obtain money, credit, loans, goods, services, or any other benefit, and I am a victim of identity theft within the meaning of 18 U.S.C. § 1028 and applicable state law.
8. The identity theft occurred on or about ________, and was discovered by me on or about ________.
9. The identity theft occurred in the following manner:

________

10. The following accounts, transactions, or instruments were fraudulently opened, accessed, or used without my knowledge or authorization (including creditor names, account numbers, and amounts where known):

________

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________

§ 3. LAW ENFORCEMENT ACTIONS AND AUTHORIZATION

12. I am willing to assist, to the best of my ability, in the investigation and prosecution of the person or persons who committed this fraud.
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14. I have reported, or will report, this matter to law enforcement. The report was made to ________ on ________, and was assigned report or case number ________. A copy of the report is attached to this Affidavit, if available.

§ 4. SUPPORTING DOCUMENTATION

15. I am providing the following supporting documentation in connection with this Affidavit:

________

§ 5. DECLARATION UNDER PENALTY OF PERJURY

I declare under penalty of perjury under the laws of the United States of America and the State of ________ that the foregoing statements are true and correct to the best of my knowledge, information, and belief. I understand that knowingly making a false statement in this Affidavit may subject me to criminal penalties under 18 U.S.C. § 1001 and applicable state law.

IN WITNESS WHEREOF, I have executed this Affidavit of Identity Theft on the date set forth below.

_________________________________
________
Affiant Signature

Date: ________

NOTARY ACKNOWLEDGMENT

State of ________, County of ________.

Subscribed and sworn (or affirmed) to before me on this ________ day of ________, ________, by ________, who is personally known to me or who produced ________ as identification.

_________________________________
Signature, Notary Public

Printed Name: ________

My commission expires: ________

(Notary Seal)