FTC Fraud Affidavit Form; Fill Out/Read Carefully

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David A. Szwak

FTC Fraud Affidavit Form; Fill Out/Read Carefully

Postby David A. Szwak » Thu Nov 03, 2005 8:28 pm

Instructions for Completing the ID Theft Affidavit

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. While many companies accept this affidavit, others 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 the companies to investigate the fraud and decide the outcome of your claim. If someone made unauthorized charges to an existing account, call the company for instructions. 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 company you need to write to. When you send the affidavit to the companies, 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. Complete this affidavit as soon as possible. Many creditors ask that you send it within two weeks. Delays on your part could slow the investigation. Be as accurate and complete as possible. You may choose not to provide some of the information requested. However, incorrect or incomplete information will slow the process of investigating your claim and absolving the debt. Print clearly. When you have finished completing the affidavit, mail a copy to each creditor, bank, or company that provided the thief with the unauthorized credit, goods, or services you describe.

Attach a copy of the Fraudulent Account Statement with information only on accounts opened at the institution to which you are sending the packet, as well as any other supporting documentation you are able to provide. Send the appropriate documents to each company by certified mail, return receipt requested, so you can prove that it was received. The companies will review your claim and send you a written response telling you the outcome of their investigation. 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: 1-800-525-6285; www.equifax.com

• Experian: 1-888-EXPERIAN (397-3742); www.experian.com

• TransUnion: 1-800-680-7289; www.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. The security or fraud department of each company where you know, or believe,
accounts have been tampered with or opened fraudulently. Close the accounts.
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.

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 www.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 www.consumer.gov/idtheft. If you don’t have Internet access, call the FTC’s Identity Theft Hotline, toll-free: 1-877-IDTHEFT (438-4338); TTY: 1-866-653-4261; or write: Identity Theft Clearinghouse, Federal Trade Commission, 600 Pennsylvania Avenue, NW, Washington, DC 20580.

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 Theft Affidavit

Name __________________________________
Phone number ___________________________
Page 1


Name __________________________________
Phone number ___________________________
Page 2

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 described in this report.

(13) ❑ My identification documents (for example, credit cards; birth certificate; driver’s license; Social Security card; etc.) were ❑ stolen ❑ lost on or about _________________.

(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 (if known) Additional information (if known)

(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) ❑ 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.)

Name __________________________________
Phone number ___________________________
Page 3

Victim’s Law Enforcement Actions

(17) (check one) I ❑ am ❑ am not willing to assist in the prosecution of the person(s) who committed this fraud.

(18) (check one) I ❑ am ❑ 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) (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:
_____________________________ _________________________________
(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) ❑ 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).

(22) ❑ A copy of the report you 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.


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 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)

[Check with each company. Creditors sometimes require notarization. If they do not, please have one witness (non-relative) sign below that you completed and signed this affidavit.]

_______________________________________ _______________________________________
(signature) (printed name)
_______________________________________ _______________________________________
(date) (telephone number)
Name __________________________________
Phone number___________________________
Page 4

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:

Completing this 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).

Fraudulent Account Statement

Creditor Name/Address (the company that opened the account or provided the goods or
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

❑ During the time of the accounts described above, I had the following account open with your company:
Billing name
Billing address________________________________________________________________
Account number _______________________________________________________________________

Example National Bank
22 Main Street
Columbus, Ohio 22722
01234567-89 auto loan 01/05/2002 $25,500.00

Name __________________________________
Phone number_______________________

Page 5


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