Identity Theft

Complaint Form
ANDREW BAILEY ago.mo.gov
800-392-8222
MISSOURI ATTORNEY GENERAL

If you would like to file a complaint regarding Identity Theft, please complete and mail this form to:
Missouri Attorney General’s Office • Consumer Protection Unit • P.O. Box 899 • Jefferson City, MO 65102

Information About Consumer

YOUR NAME
First Last Mi

ADDRESS
Street City State Zip County

E-MAIL

PRIMARY PHONE NO. ( ) -

SECONDARY PHONE NO. ( ) -

Information About Complaint

HOW DID YOU BECOME AWARE OF THE IDENTITY CRIME?

Found fraudulent charges on my credit card bill or my cell phone bill.
Received bills for an account(s) I did not open.
Found irregularities on my credit report.
Was contacted by a creditor demanding payment.
Was contacted by a bank’s fraud department about charges.
Was denied a loan or credit.
Was arrested, had a warrant issued, or a complaint filed in my name for a crime I did not commit.
Was sued for a debt I did not incur.
Was not regularly receiving bills for a legitimate account.
Was denied employment.
Had my driver’s license suspended for actions I did not commit.
Received notice of a legal action I did not file, such as bankruptcy.
Had my tax return rejected because someone filed in my name.
Received a notice of a data breach in the mail or by email.
Other

PLEASE EXPLAIN IN MORE DETAIL THE ITEM(S) YOU CHECKED ABOVE. You may attach a separate sheet of paper if you need more space.

Page 1 Modified January 2019

 Identity Theft
Complaint Form
ANDREW BAILEY ago.mo.gov
800-392-8222
MISSOURI ATTORNEY GENERAL

Information About Complaint (Con’t)

WHAT DATE DID YOU FIRST BECOME AWARE OF THE IDENTITY CRIME? / / 2 0
MM / DD/ YYYY

WHEN DID THE FRAUDULENT ACTIVITY BEGIN? / / 2 0

MM / DD/ YYYY

WHAT IS THE FULL NAME, ADDRESS & OTHER IDENTIFYING INFORMATION THAT THE FRAUDULENT ACTIVITY WAS MADE UNDER?

Name
First Middle Last

Address
Street City State Zip County

PLEASE LIST ALL FRAUDULENT ACTIVITY THAT YOU ARE AWARE OF TO DATE, WITH THE LOCATIONS AND ADDRESSES OF WHERE
THE FRAUDULENT APPLICATIONS OR PURCHASES WERE MADE. LIST IN CHRONOLOGICAL ORDER, IF POSSIBLE. PLEASE BE
CONCISE AND STATE THE FACTS. You may attach copies of supporting documents/notes you have.

Page 2 Modified January 2019

 Identity Theft
Complaint Form
ANDREW BAILEY ago.mo.gov
800-392-8222
MISSOURI ATTORNEY GENERAL

Information About Complaint (Con’t)

TO THE BEST OF YOUR KNOWLEDGE AT THIS POINT, WHAT IDENTITY CRIMES HAVE BEEN COMMITTED?
Making purchase(s) using my credit cards or credit card numbers without authoriziation.
Opening new credit card accounts in my name.
Opening utility and/or telephone accounts in my name.
Unauthorized withdrawals from my bank accounts.
Opening new bank accounts in my name.
Taking out unauthorized loans in my name.
Unauthorized access to my securities or investment accounts.
Obtaining government benefits in my name.
Obtaining employment in my name.
Obtaining medical services or insurance in my name.
Evading prosecution for crimes committed by using my name or committing new crimes under my name.
Check fraud.
Passport/visa fraud.
Filing a tax return in my name.
Obtaining services or credit in my child or my foster child’s name.
Other (please explain)

DO YOU HAVE ANY INFORMATION ON A SUSPECT IN THIS IDENTITY CRIME CASE? IF SO, PLEASE PROVIDE AS MUCH INFORMATION
AS POSSIBLE ABOUT THE SUSPECT, INCLUDING THE SUSPECT’S FULL NAME, PHONE NUMBER AND ADDRESS.

Suspect’s Name
First Middle Last

Address
Street City State Zip County

HOW DO YOU BELIEVE THE IDENTITY CRIME OCCURRED?

Page 3 Modified January 2019

 Identity Theft
Complaint Form
ANDREW BAILEY ago.mo.gov
800-392-8222
MISSOURI ATTORNEY GENERAL

Information About Complaint (Con’t)

PLEASE LIST ANY GOVERNMENT DOCUMENTS FRAUDULENTLY OBTAINED IN YOUR NAME.

(DRIVER’S LICENSES, SOCIAL SECURITY CARDS, ETC.)

HAVE YOU CONTACTED THE FOLLOWING ORGANIZATIONS & REQUESTED A FRAUD ALERT TO BE PUT ON YOUR ACCOUNT?
(Check all that apply.)

Equifax. Date? TransUnion. Date?

Experian. Date? Your bank(s). Names of bank(s):

Department of Motor Vehicles. Social Security Administration

Other:

HAVE YOU REQUESTED A CREDIT FREEZE WITH A CREDIT REPORTING AGENCY?

HAVE YOU REQUESTED A CREDIT REPORT FROM EACH OF THE THREE CREDIT BUREAUS? (Check all that apply.)

Equifax
If you have any reports, please attach a copy of each to this form.
TransUnion
Please keep your original documents in a safe place. Send
Experian
ONLY COPIES to the Attorney General’s Office at this time.

Your Verification
BY FILING THIS COMPLAINT, I UNDERSTAND THAT:
The Attorney General is not my private attorney, but enforces state consumer protection laws;
I would be willing to testify in court to the fact stated in this complaint; and
In accordance with Missouri law, consumer complaints are “public records,” subject to public disclosure upon request. My complaint, including
my name, address and related documents, may be provided pursuant to a Sunshine Law request.

I ATTEST TO THE ACCURACY OF STATEMENTS MADE IN THIS COMPLAINT:

YOUR SIGNATURE DATE / / 2 0

MM / DD/ YYYY

Page 4 Modified January 2019