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 didnt 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, drivers 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.

DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER

GOVERNMENT AGENCY

If you havent 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.
Its 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 mothers 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 Generals 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 dont
have Internet access, call the FTCs 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.

DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER

GOVERNMENT AGENCY

Name __________________________________ Phone number _______________________ Page 1

ID Theft 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 drivers 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 (____)____________________

DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER

GOVERNMENT AGENCY

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; drivers license;
Social Security card; etc.) were stolen lost on or about __________________.
(day/month/year)
(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, mothers maiden name, etc.) or identification documents to get money, credit,
loans, goods or services without my knowledge or authorization:
_________________________________
Name (if known)
_________________________________
Address (if known)
_______________________________
Phone number(s) (if known)
_________________________________
Additional information (if known)

____________________________________
Name (if known)
____________________________________
Address (if known)
____________________________________
Phone number(s) (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.)

DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER

GOVERNMENT AGENCY

Name

__________________________________ Phone number _______________________ Page 3

Victims Law Enforcement Actions

(17) (check one) I am
committed this fraud.

am not

willing to assist in the prosecution of the person(s) who

(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)
____________________________
(Date of report)
_____________________________
(Phone number)

_________________________________
(Officer/Agency personnel taking report)
_________________________________
(Report number, if any)
_________________________________
(email address, if any)

_____________________________
(Agency #2)
_____________________________
(Date of report)
_____________________________
(Phone number)

_________________________________
(Officer/Agency personnel taking report)
_________________________________
(Report number, if any)
_________________________________
(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 drivers
license, state-issued ID card or your passport). If you are under 16 and dont 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).

DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER

GOVERNMENT AGENCY

Name

__________________________________ Phone number _______________________ Page 4

(22) A copy of the report you filed with the police or sheriffs 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.
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 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)

______________________________________
(Notary)
[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.]
Witness:
_______________________________________
(signature)

__________________________________
(printed name)

_______________________________________
(date)

__________________________________
(telephone number)

DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER

GOVERNMENT AGENCY

Name

__________________________________ Phone number _______________________ Page 5

Fraudulent Account Statement

Completing this Statement
Make as many copies of this page as you need. Complete a separate page for each
company youre notifying and only send it to that company. Include a copy of your
signed affidavit.
List only the account(s) youre 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 (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:
Creditor Name/Address
Account
(the company that opened the
Number
account or provided the goods or
services)

Example
Example National Bank
22 Main Street
Columbus, Ohio 22722

01234567-89

Type of unauthorized
credit/goods/services
provided by creditor
(if known)

auto loan

Date
issued or
opened
(if known)

01/05/2002

Amount/Value
provided
(the amount
charged or the
cost of the
goods/services)
$25,500.00

During the time of the accounts described above, I had the following account open with your company:
Billing name ___________________________________________________________________
Billing address__________________________________________________________________
Account number _______________________________________________________________

DO NOT SEND AFFIDAVIT TO THE FTC OR ANY OTHER

GOVERNMENT AGENCY