Fillable ID Theft Affidavit Victim Information own as 2. (City of Scottsdale)

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ID Theft Affidavit Victim Information own as 2. (City of Scottsdale)

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The ID Theft Affidavit Victim Information own as 2. (City of Scottsdale) form is 5 pages long and contains:

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  • 21 check-boxes
  • 74 other fields

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File type: PDF

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Name ______________________ Scottsdale Police Department Report Number ___________________ Page 1
ID Theft Affidavit
My full legal name is ______________________________________________
Victim Information
1. My full legal name is ___________________________________________________________________
(First) (Middle) (Last) (Jr.,Sr., III)
2. (If different from above) When the events described in this affidavit took place, I was kn
own as
___________________________________________________________________________________
(First) (Middle) (Last)
(Jr., Sr., III)
3. My date of birth is __________________________
(day/month/year)
4. My Social Security Number is ____________________________________
5. My driver’s license or identification ca
rd state a
nd number are__________________________
6. My current address is __________________________________________________________________
City_____________________________State_____________________Zip Code__________
7. I have lived at this address since ______________________________
(month/year)
8. (If different from above) When the events describ
ed in this affidavit took pla
ce, my address
was________________________________________________________________________________
City__________________________________State_______________________Zip Code____________
9. I lived at the address in Item 8 from ____________until____________
(month/year) (month/year)
10. My daytime telephone number is ( ____)________________________
My evening telephone number is (_____)________________________
How the Fraud Occurred
Check all that apply for items 11 – 17:
11.
I did not authorize anyone to use my name or personal information to seek the
money, credit, loans, goods or services described in this report.
12.
I did not receive any benefit, money, goods or services as a result of the events descibed in
this report.
Name ______________________ Scottsdale Police Department Report Number ________________________ Page 2
13.
My identification documents (for example, credit cards; birth certificates; driver's license;
Social Security card; etc.) were:
stolen lost on or about ________________________________
(day/month/year)
14.
To the best of my knowledge and belief, the following person(s) used my information (for example, my
name, address, date of birth, existing account numbers, Social Security number, mother's maiden name,
etc.) or identification documents to get money, credit, loans, goods or services without my knowledge or
authorization:
________________________________ ___________________________________
Name (if known) Name (if known)
________________________________ ___________________________________
Address (if known)
Address (if known)
________________________________ ___________________________________
Phone number(s) (if known) Phone number(s) (if known)
________________________________ ___________________________________
Additional information Additional information
15.
I do NOT know who used my information or identification documents to get money, credit,
loans, goods or services without my knowledge or authorization
16.
A
dditional comments: (For example, description of the fraud, which documents or information
were used or how the identity theif gained access to your information)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(Attach additional pages as necessary.)
Name ______________________ Scottsdale Police Department Report Number _____________________ Page 3
Victim’s Law Enforcement Actions
17. (check only one)
I am willing to assist in the prosecution of the person(s) who committed this fraud.
I am NOT willing to assist in the prosecution of the person(s) who committed this fraud.
18. (check only one)
I am authorizing the release of this information to law enforcement for the purposes of assisting
them in the investigation and prosecution of the person(s) who committed this fraud.
I am NOT authorizing the release of this information to law enforcement for the purposes of assisting
them in the investigation and prosecution of the person(s) who committed this fraud.
19. (check all that apply) I
have have not reported the events described in this affidavit to the police
or other law enforcement agency. The police
did did not write a report. In the event you have
contacted the police or other law enforcement agency please complete the following information:
______________________________________ _________________________________________
(Agenc
y #1) (Officer/Age
ncy personnel taking report)
______________________________________ _________________________________________
(Date of Report) (Report number, if any)
______________________________________ __________________________________________
(Phone number) (email address, if any)
______________________________________ _________________________________________
(Agenc
y #2) (Officer/Age
ncy personnel taking report)
______________________________________ _________________________________________
(Date of Report) (Report number, if any)
______________________________________ __________________________________________
(Phone number) (email address, if any)
Documentation Checklist
Please indicate the supporting documentation you are able to provide to the comp
anies you plan notify.
Attach copies (NOT originals) to the affidavit before sending it to the companies.
20.
A
copy of a valid government-issued photo-identification card (for example, your driver's license, state-
issued ID card, or your passport.) If you are under 16 and don't have a photo-ID, you may submit a copy of
your birth certificate or a copy of your official school records showing your enrollment and place of
residence.
21.
Proof of residency during the time the disputed bill occurred, the loan was made or the other event took place
(for example, a rental/lease agreement in your name, a copy of a utility bill or a copy of an insurance bill.
Name ______________________ Scottsdale Police Department Report Number ________________________ Page 4
22.
A
copy of the report filed with the police or sheriff's department. If you are unable to obtain a report or report
number from the police, please indicate that in Item 19. Some companies only need the report number, not a
copy of the report. You may want to check with each company.
Si
g
nature
I certify that, to the best of my knowledge and beli
e
f, all the information on and attached to this
affidavit is true, correct, and complete and made in good faith. I also understand that this affidavit 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 constitute a violation of 18 U.S.C. 1001 or
other federal, state or local criminal statutes, and may result in imposition of a fine or imprisonment or both
______________________________________ _____________________________________
(signature) (date signed)
_______________________________________
(Notary)
[Check with each company. Creditors sometimes require nota
r
ization. If they do not, please have one
witness (non-relative) sign below that you completed and signed this affidavit.]
Witness:
______________________________________ ___________________________________
(signature) (printed name)
______________________________________ ____________________________________
(date) (telephone number)
Name ______________________ Scottsdale Police Department Report Number _____________________ Page 5
Fraudulent Account Statement
Completing the Statement
• Make as many copies of this page as you need. Complete a separate page for each
company you’re notifyin
g and only send it to that company. Include a copy of your
signed affidavit.
• List only the account(s) you’re disputing with the company receiving this form. See
the example below.
•
If a collection agency sent you a statement, letter or notice about the fraudulent
account, att
ach a copy of that docu
ment (NOT the original).
I declare (check all that apply):
As a result of the event(s) described in the ID Theft Affidavit, the following account(s) was/were opened at
your company in my name without my knowledge, permission or authorization using my personal information
or identifying documents:
Creditor
Name/Address
(the company that opened
the account or provided the
goods or services)
Account
Number
Type of unauthorized
Credit/goods/services
Provided by creditor
(
If known)
Date
Issued or
Opened
(if known)
Amount/Value
provided
(the amount charged or
the cost of the
goods/services)
Example
Example National Bank
22 Main Street
Columbus, OH 22722
01234567-89
Auto Loan
01/05/2002
$25,500.00
During the time of the accounds described above, I had the following account open with your company:
Billing name: ___________________________________________________________________
Billing address: ___________________________________________________
______________
Account number: ________________________________________________________________
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ID Theft Affidavit Victim Information own as 2. (City of Scottsdale)

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Completed 16 July 2020

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