FTC Identity Theft Complaint Letter - Template Form Pro · US-law

________
________
Telephone: ________
Email: ________

Date: ________

Consumer Response Center
Federal Trade Commission
600 Pennsylvania Avenue, N.W.
Washington, DC 20580

Re: Identity Theft Complaint — Notice Pursuant to the Fair Credit Reporting Act (15 U.S.C. § 1681 et seq.) and the Identity Theft and Assumption Deterrence Act (18 U.S.C. § 1028)

To Whom It May Concern:

§ 1. Purpose of Notice. I am submitting this letter to formally notify the Federal Trade Commission (the “FTC”) that I am a victim of identity theft and that my personal identifying information has been obtained and used without my authorization for fraudulent purposes. This letter follows up on and confirms the communication I had with a representative of the FTC on ________ concerning the theft of my identity, and is intended to support the creation of an Identity Theft Report as contemplated by 15 U.S.C. § 1681a(q)(4).

§ 2. Verification of Identity. For purposes of confirming my identity, my full legal name is ________, my Social Security number is ________, and my date of birth is ________. I request that this sensitive information be maintained in accordance with applicable privacy laws and FTC procedures.

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1. Credit card accounts;
2. Checking and/or savings accounts;
3. Loans and/or lines of credit;
4. Utility accounts;
5. Investment accounts;
6. Internet and/or email accounts;
7. Government documents and/or benefits;
8. Other forms of fraud, as follows: ________

§ 4. Description of the Incident. The facts and circumstances of the identity theft incident, to the best of my knowledge and belief, are as follows: ________. The fraudulent activity is believed to have first occurred or been discovered on or about ________.

§ 5. Harm and Consequences. As a direct result of this identity theft, I have suffered one or more of the following forms of harm (those applicable are indicated and further described where noted):

1. A civil suit or judgment has been filed against me;
2. A criminal investigation, arrest, or conviction has been initiated or entered against me;
3. I was denied banking, investment, credit, or other financial services;
4. I was denied employment or lost existing employment;
5. I have been pursued by debt collectors and/or creditors for obligations I did not incur;
6. Additional harm, as follows: ________

§ 6. Information Concerning the Suspect. I have the following information, if any, regarding the identity of the person(s) I believe to be responsible for this fraud: ________.

§ 7. Contact with Consumer Reporting Agencies. I have contacted the following consumer reporting agency or agencies: ________, for one or more of the following purposes:

1. To notify the agency or agencies of the identity theft and to report the resulting fraud;
2. To place an initial or extended fraud alert on my consumer file pursuant to 15 U.S.C. § 1681c-1;
3. To request a security freeze on my credit pursuant to 15 U.S.C. § 1681c-1(i);
4. To obtain a copy of my consumer credit report.

§ 8. Police Report. I have contacted the following law enforcement agency: ________, located in ________, in the State of ________, and have filed a report bearing report number ________ on ________. A copy of that report is enclosed with this letter.

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§ 10. Declaration. I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct to the best of my knowledge and belief.

Thank you for your attention to this matter.

Sincerely,

________
Signature: ______________________
Date: ________

Enclosures: ________