To make certain that you do not become responsible for any debts incurred by an identity thief, you must prove to each of the
companies where accounts were opened or used in your name that you didn’t create the debt.
A group of credit grantors, consumer advocates, and attorneys at the Federal Trade Commission (FTC) developed an ID Theft
Affidavit to make it easier for fraud victims to report information. Nicor Gas utilizes this form and in addition requires a copy
of a police report, proof of residency during disputed time frame and a copy of a photo I.D. to be attached to your submission.
A completed ID Theft Affidavit must be submitted in order to prove that you did not open or post unauthorized charges to
a Nicor Gas account. Other companies could require that you submit more or different forms. Before you send the affidavit,
contact each company to find out if they accept it.
It will be necessary to provide the information in this affidavit anywhere a new account was opened in your name.
The information will enable Nicor Gas to investigate the fraud and decide the outcome of your claim. If someone made
unauthorized changes to an existing account, please call the company at 888.Nicor4U (888.642.6748) to discuss with one of
our call center representatives.
This affidavit has two parts:
Part One – the ID Theft Affidavit – is where you report general information about yourself and the theft.
Part Two – the Fraudulent Account Statement – is where you describe the fraudulent account(s) opened in your name. Use a
separate Fraudulent Account Statement for each account if there are multiple accounts or address included in your claim.
The above information can be submitted via facsimile to 630.388.3863 or via US Mail to PO Box 190, Aurora, IL 60507. When
you send the affidavit via US Mail, attach copies (NOT originals) of any supporting documents (for example, driver’s license or
police report). Before submitting your affidavit, review the disputed account(s) with family members or friends who may have
information about the account(s) or access to them.
Be as accurate and complete as possible. Incorrect or incomplete information will slow the process of investigating your
claim and absolving the debt. Nicor Gas cannot investigate your claim until you proved all of the required information on the
affidavit. Print clearly.
Nicor Gas will review your claim and send you a written response telling you the outcome of the investigation within 30 days.
Keep a copy of everything you submit. If you are unable to complete the affidavit, a legal guardian or someone with power of
attorney may complete it for you. Except as noted, the information you provide will be used only by the company to process
your affidavit, investigate the events you report, and help stop further fraud. If this affidavit is requested in a lawsuit, the
company might have to provide it to the requesting party. Completing this affidavit does not guarantee that the identity thief
will be prosecuted or that the debt will be cleared.
If you haven’t already done so, report the fraud to the following organizations:
1. Any one of the nationwide consumer reporting companies to place a fraud alert on your credit report. Fraud alerts can help
prevent an identity thief from opening any more accounts in your name. The company you call is required to contact the
other two, which will place an alert on their versions of your report, too.
· Equifax 800.525.6285 equifax.com
· Experian 888.EXPERIAN (397.3742) experian.com
· TransUnion 800.680.7289 transunion.com
In addition to placing the fraud alert, the three consumer reporting companies will send you free copies of your credit
reports, and, if you ask, they will display only the last four digits of your Social Security number on your credit reports.
2. Close the accounts where you believe the fraud/theft has occurred. Follow up in writing, and include copies (NOT originals)
of supporting documents. It’s important to notify credit card companies and banks in writing. Send your letters by
certified mail, return receipt requested, so you can document what the company received and when. Keep a file of your
correspondence and enclosures.
When you open new accounts, use new Personal Identification Numbers (PINs) and passwords. Avoid using easily available
information like your mother’s maiden name, your birth date, the last four digits of your Social Security number or your
phone number, or a series of consecutive numbers.
Instructions for completing the ID The Affidavit
3. Your local police or the police in the community where the identity theft took place to file a report. Get a copy of the police
report or, at the very least, the number of the report. It can help you deal with creditors who need proof of the crime. If the
police are reluctant to take your report, ask to file a “Miscellaneous Incidents” report, or try another jurisdiction, like your
state police. You also can check with your state Attorney General’s office to find out if state law requires the police to take
reports for identity theft. Check the Blue Pages of your telephone directory for the phone number or check naag.org for a
list of state Attorneys General.
4. The Federal Trade Commission. By sharing your identity theft complaint with the FTC, you will provide important
information that can help law enforcement officials across the nation track down identity thieves and stop them. The FTC
also can refer victims’ complaints to other government agencies and companies for further action, as well as investigate
companies for violations of laws that the FTC enforces.
You can file a complaint online at consumer.gov/idtheft. If you don’t have internet access, call the FTC’s Identity Theft
Hotline, toll-free: 877.IDTHEFT (438.4338); TTY: 866.653.4261; or write: Identity Theft Clearinghouse, Federal Trade
Commission, 600 Pennsylvania Avenue, NW, Washington, DC 20580.
Instructions for completing the ID The Affidavit
ID The Affidavit
1
Name Phone number
ID The Affidavit
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 known 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 card state and 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 described in this affidavit took place, 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 ( )
ID The Affidavit
2
Name Phone number
ID The Affidavit
How the Fraud Occurred
Check all that apply for items 11 –17:
( 11 )
o
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 )
o
I did not receive any benefit, money, goods or services as a result of the events described in this
report.
( 13 )
o
My identification documents (for example, credit cards, birth certificate, driver’s license, Social
Security card, etc.) were
o
stolen
o
lost on or about .
( 14 )
o
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 (if known) Additional information (if known)
( 15 )
o
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 ) Additional comments: (For example, description of the fraud, which documents or information were used
or how the identity thief gained access to your information.)
(Attach additional pages as necessary.)
ID The Affidavit
3
Name Phone number
ID The Affidavit
Victims Law Enforcement Actions
( 17 )
(select one) I
o
am
o
am not willing to assist in the prosecution of the person(s) who committed this
fraud.
( 18 )
(select one) I
o
am
o
am not authorizing the release of this information to law enforcement for
the purpose of assisting them in the investigation and prosecution of the person(s) who committed
this fraud.
( 19 )
(select the options that apply) I
o
have
o
have not reported the events described in this affidavit to
the police or other law enforcement agency. The police
o
did
o
did not write a report. In the event
you have contacted the police or other law enforcement agency, please complete the following:
(Agency #1) (Officer/Agency personnel taking report)
(Date of report) (Report number if any)
(Phone number) (Email address, if any)
(Agency #2) (Officer/Agency 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 companies you plan to notify.
Attach copies (NOT originals) to the affidavit before sending it to the companies.
( 20 )
o
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 )
o
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).
( 22 )
o
A copy of the report you filed with the police or sheriff ’s department.
ID The Affidavit
4
Name Phone number
ID The Affidavit
Signature
I certify that, to the best of my knowledge and belief, all the information on and attached to this affidavit is
true, correct, and complete and made in good faith. I also understand that is affidavit or the information it con-
tains 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)
(Date) (Telephone number)
ID The Affidavit
5
Name Phone number
ID The Affidavit
Fraudulent Account Statement
• Make as many copies of this page as you need. Complete a separate page for each company you’re notifying
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, attach a copy of
that document (NOT the original).
I declare:
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:
Name and Address
(the name and address
of the opened account)
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)
During the time of the accounts described above, I had the following account open with your company:
Billing name
Billing address
Account number
Example
Nicholas Nicor
123 Main Street
Clancy, IL 22722
01234567-89
00/00/2XXX
$25,000.00
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