Average time to complete: 10 minutes
Identity Theft Victims Complaint and Affidavit
A voluntary form for filing a report with law enforcement, and disputes with credit reporting agencies and creditors about
identity theft-related problems. Visit ftc.gov/idtheft to use a secure online version that you can print for your records.
Before completing this form:
1. Place a fraud alert on your credit reports, and review the reports for signs of fraud.
2. Close the accounts that you know, or believe, have been tampered with or opened fraudulently.
About You (the victim)
Now
(1)
My full legal name: ________________________________________________
(2)
My date of birth: __________________
(3)
My Social Security number: ________-______-__________
(4)
My drivers license: _________
(5)
My current street address:
First
Middle
Last
Suffix
mm/dd/yyyy
___________________
State
Number
____________________________________________________________________________
Number & Street Name
Apartment, Suite, etc.
_______________________________________________________________
(6)
I have lived at this address since ____________________
(7)
My daytime phone: (____)___________________
My evening phone: (____)___________________
My email: ______________________________________
City
State
Zip Code
Country
Leave (3)
blank until
you provide
this form to
someone with
a legitimate
business need,
like when you
are filing your
report at the
police station
or sending
the form
to a credit
reporting
agency to
correct your
credit report.
mm/yyyy
At the Time of the Fraud
Skip (8) - (10)
if your
information
has not
changed since
the fraud.
(8)
My full legal name was: ____________________________________________
(9)
My address was: _________________________________________________
_______________________________________________________________
(10)
My daytime phone: (____)_________________ My evening phone: (____)_________________
My email: _____________________________________
First
Middle
Number & Street Name
City
State
Last
Suffix
Apartment, Suite, etc.
Zip Code
Country
The Paperwork Reduction Act requires the FTC to display a valid control number (in this case, OMB control #3084-0047)
before we can collect or sponsor the collection of your information, or require you to provide it.
Victims Name _______________________________ Phone number (____)_________________ Page 2
About You (the victim) (Continued)
Declarations
(11) I
did OR
did not
authorize anyone to use my name or personal information to
obtain money, credit, loans, goods, or services or for any
other purpose as described in this report.
(12) I
did OR
did not
receive any money, goods, services, or other benefit as a
result of the events described in this report.
(13) I
am OR
am not
willing to work with law enforcement if charges are brought
against the person(s) who committed the fraud.
About the Fraud
(14)
I believe the following person used my information or identification
documents to open new accounts, use my existing accounts, or commit other
fraud.
Name: ___________________________________________________
Address: __________________________________________________
__________________________________________________________
Phone Numbers: (____)_______________ (____)________________
First
Middle
Last
Number & Street Name
City
State
Suffix
Apartment, Suite, etc.
Zip Code
(14):
Enter what
you know
about anyone
you believe
was involved
(even if you
dont have
complete
information).
Country
Additional information about this person: _____________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Victims Name _______________________________ Phone number (____)_________________ Page 3
(15)
Additional information about the crime (for example, how the identity thief
(14) and (15):
gained access to your information or which documents or information were
Attach
additional
used):
sheets as
________________________________________________________________
needed.
________________________________________________________________
________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Documentation
(16)
I can verify my identity with these documents:
A valid government-issued photo identification card (for example, my drivers
license, state-issued ID card, or my passport).
If you are under 16 and dont have a photo-ID, a copy of your birth certificate or
a copy of your official school record showing your enrollment and legal address is
acceptable.
Proof of residency during the time the disputed charges occurred, the loan
was made, or the other event took place (for example, a copy of a rental/lease
agreement in my name, a utility bill, or an insurance bill).
(16): Reminder:
Attach copies
of your identity
documents
when sending
this form to
creditors
and credit
reporting
agencies.
About the Information or Accounts
(17)
The following personal information (like my name, address, Social Security number, or date of
birth) in my credit report is inaccurate as a result of this identity theft:
(A) __________________________________________________________________________
(B) __________________________________________________________________________
(C) __________________________________________________________________________
(18)
Credit inquiries from these companies appear on my credit report as a result of this identity
theft:
Company Name: _______________________________________________________________
Company Name: _______________________________________________________________
Company Name: _______________________________________________________________
Victims Name _______________________________ Phone number (____)_________________ Page 4
(19) Below are details about the different frauds committed using my personal information.
___________________________________________________________________
Name of Institution
Contact Person
Phone
Extension
___________________________________________________________________
Account Number
Account Type:
Routing Number
Affected Check Number(s)
Credit
Bank
Phone/Utilities
Loan
Government Benefits
Internet or Email
Other
Select ONE:
This account was opened fraudulently.
This was an existing account that someone tampered with.
___________________________________________________________________
Date Opened or Misused (mm/yyyy)
Date Discovered (mm/yyyy)
Total Amount Obtained ($)
___________________________________________________________________
Name of Institution
Contact Person
Phone
Extension
___________________________________________________________________
Account Number
Account Type:
Routing Number
Affected Check Number(s)
Credit
Bank
Phone/Utilities
Loan
Government Benefits
Internet or Email
Other
Select ONE:
This account was opened fraudulently.
This was an existing account that someone tampered with.
___________________________________________________________________
Date Opened or Misused (mm/yyyy)
Date Discovered (mm/yyyy)
Total Amount Obtained ($)
___________________________________________________________________
Name of Institution
Contact Person
Phone
Extension
___________________________________________________________________
Account Number
Account Type:
Routing Number
Affected Check Number(s)
Credit
Bank
Phone/Utilities
Loan
Government Benefits
Internet or Email
Other
Select ONE:
This account was opened fraudulently.
This was an existing account that someone tampered with.
___________________________________________________________________
Date Opened or Misused (mm/yyyy)
Date Discovered (mm/yyyy)
Total Amount Obtained ($)
(19):
If there were
more than three
frauds, copy this
page blank, and
attach as many
additional copies
as necessary.
Enter any
applicable
information that
you have, even if
it is incomplete
or an estimate.
If the thief
committed two
types of fraud at
one company,
list the company
twice, giving
the information
about the two
frauds separately.
Contact Person:
Someone you
dealt with, whom
an investigator
can call about this
fraud.
Account Number:
The number of
the credit or
debit card, bank
account, loan, or
other account
that was misused.
Dates: Indicate
when the thief
began to misuse
your information
and when you
discovered the
problem.
Amount Obtained:
For instance,
the total amount
purchased with
the card or
withdrawn from
the account.
Victims Name _______________________________ Phone number (____)_________________ Page 5
Your Law Enforcement Report
(20)
One way to get a credit reporting agency to quickly block identity theftrelated information from appearing on your credit report is to submit a
detailed law enforcement report (Identity Theft Report). You can obtain
an Identity Theft Report by taking this form to your local law enforcement
office, along with your supporting documentation. Ask an officer to witness
your signature and complete the rest of the information in this section. Its
important to get your report number, whether or not you are able to file in
person or get a copy of the official law enforcement report. Attach a copy of
any confirmation letter or official law enforcement report you receive when
sending this form to credit reporting agencies.
Select ONE:
I have not filed a law enforcement report.
I was unable to file any law enforcement report.
I filed an automated report with the law enforcement agency listed
below.
I filed my report in person with the law enforcement
officer and agency listed below.
Automated report:
A law
enforcement
report filed
through an
automated
system, for
example, by
telephone, mail,
or the Internet,
instead of a
face-to-face
interview with a
law enforcement
officer.
____________________________________________________________________
Law Enforcement Department
____________________________
Report Number
(20):
Check I have
not... if you have
not yet filed a
report with law
enforcement or
you have chosen
not to. Check I
was unable... if
you tried to file
a report but law
enforcement
refused to take it.
State
_____________________
Filing Date (mm/dd/yyyy)
____________________________________________________________________
Officers Name (please print)
____________________________
Badge Number
Officers Signature
(____)_______________
Phone Number
Did the victim receive a copy of the report from the law enforcement officer?
Victims FTC complaint number (if available): ________________________
Yes
OR
No
Victims Name _______________________________ Phone number (____)_________________ Page 6
Signature
As applicable, sign and date IN THE PRESENCE OF a law enforcement officer, a notary, or
a witness.
(21)
I certify that, to the best of my knowledge and belief, all of the information on and attached to
this complaint is true, correct, and complete and made in good faith. I understand that this
complaint 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 violate federal, state, or local criminal statutes, and may result in a fine,
imprisonment, or both.
_______________________________________
Signature
_________________________________________
Date Signed (mm/dd/yyyy)
Your Affidavit
(22)
If you do not choose to file a report with law enforcement, you may use this form as an Identity
Theft Affidavit to prove to each of the companies where the thief misused your information that
you are not responsible for the fraud. While many companies accept this affidavit, others require
that you submit different forms. Check with each company to see if it accepts this form. You
should also check to see if it requires notarization. If so, sign in the presence of a notary. If it
does not, please have one witness (non-relative) sign that you completed and signed this Affidavit.
_______________________________________
Notary
Witness:
_______________________________________
_________________________________________
_______________________________________
_________________________________________
Signature
Date
Printed Name
Telephone Number
