AFFIDAVIT OF IDENTITY THEFT
Victim Information:
My full legal name is ________ and I was born on ________. My social security number is ________. My driver's license or state ID number is ________.
I have lived at the following address since ________:
________
The best way to contact me is through the following:
________
Description of Identity Theft:
The identity theft happened in the following manner:
________
To the best of my knowledge and belief, the following person used my information or identification documents to get benefits, money, goods, and/or services without my knowledge or authorization:
________
Law Enforcement Actions:
I am willing to assist to the best of my abilities in the prosecution of the person(s) who committed this fraud.
I am authorizing the release of this information to any law enforcement officials for the purpose of assisting them in their investigation and prosecution of any persons involved in this fraud.
I have reported this fraud to the police or other law enforcement agencies. I have attached the police report to this affidavit.
Supporting Documentation:
I am providing the following supporting documentation:
________
Signature:
5 5288552 52525 2225822 22 2252552 2552 252 82225252822 5 5582 25288525 82 2588 522855882 88 2552 525 8255282 22 252 8282 22 22 222882522.
_________________________________
________
____________
Date
Subscribed and sworn (or affirmed) to before me on this ______ day of ___________________, ________.
_________________________________
Signature, Notary Public
AFFIDAVIT OF IDENTITY THEFT
Victim Information:
My full legal name is ________ and I was born on ________. My social security number is ________. My driver's license or state ID number is ________.
I have lived at the following address since ________:
________
The best way to contact me is through the following:
________
Description of Identity Theft:
The identity theft happened in the following manner:
________
To the best of my knowledge and belief, the following person used my information or identification documents to get benefits, money, goods, and/or services without my knowledge or authorization:
________
Law Enforcement Actions:
I am willing to assist to the best of my abilities in the prosecution of the person(s) who committed this fraud.
I am authorizing the release of this information to any law enforcement officials for the purpose of assisting them in their investigation and prosecution of any persons involved in this fraud.
I have reported this fraud to the police or other law enforcement agencies. I have attached the police report to this affidavit.
Supporting Documentation:
I am providing the following supporting documentation:
________
Signature:
5 5288552 52525 2225822 22 2252552 2552 252 82225252822 5 5582 25288525 82 2588 522855882 88 2552 525 8255282 22 252 8282 22 22 222882522.
_________________________________
________
____________
Date
Subscribed and sworn (or affirmed) to before me on this ______ day of ___________________, ________.
_________________________________
Signature, Notary Public
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