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 ________:

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The best way to contact me is through the following:

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Description of Identity Theft:

The identity theft happened in the following manner:

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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:

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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:

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Signature:

I declare under penalty of perjury that the information I have provided in this affidavit is true and correct to the best of my knowledge.

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Date

Subscribed and sworn (or affirmed) to before me on this ______ day of ___________________, ________.

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Signature, Notary Public