Form Letter 117L – 2
Identity Theft and the Deceased

This letter form is a affidavit of fact to be sent to the creditors or merchants if identity theft has occured.

NOTE: Only the surviving spouse, someone with power of attorney for the deceased, or the executor of the estate may request this informaiton. For more informaiton on what is required by the three Credit Reporting Agencies please see our Fact Sheet 117.

Form Letter #117-2:

NOTICE OF IDENTITY THEFT-

Affidavit of Fact:

Sent via (include all that apply) email/ fax/ certified return receipt requested mail to:

Name of company:

Investigator:

Address:

Other contact info:

Today’s Date:

I have become aware that (deceased name) has become a victim of identity theft. Person reporting the fraud: (documentation of relationship attached if appropriate)

My Name:

Address:

City/State/Zip:

Phone Number: Daytime- Evening-

Email address:

Relationship to Deceased:

As the (relationship to deceased- i.e. surviving spouse) _________________, I am notifying you that the following person died and that they appear to have been a victim of identity theft, financial fraud or false personation.

Information about the deceased: (copy of death certificate attached)

Full legal name of deceased:

Date of death:

Time of death:

Date of birth:

Location of birth:

Social Security number of deceased:

Five year address history (most current one first):

How I Became Aware of the Fraud : (Check all that apply ) (delete underline after parentheses)

___ Received collection notice, bill, credit card for the deceased

___ Reviewed reports from credit reporting agencies

___ Notification from law enforcement, governmental agency

___ Information from family member/friend/attorney with direct knowledge of the crime

___ Other: (be specific) __________

How the Fraud Occurred: (Check all that apply)

___ To my knowledge (name of deceased) did not authorize anyone to use his/her name or personal information while alive to seek employment or to seek the money, credit, loans, goods or services described in this report.

___ (name of deceased) did not receive any benefit, money, goods or services as a result of the events described in this report.

___ (name of deceased) identification documents (i.e., credit cards; check; birth certificate; driver's license; Social Security card/number, etc.)  were stolen  were lost on or about _____________(day/month/year)

___ Credit was issued or checks were written after the time/date of death.

____ The crime occurred after the time/date of death.

___ The deceased was unable to (i.e., apply for credit, make a purchase, drive, work) on the indicated date as that person was (situation- in a coma, in the hospital in critical condition, mentally incapacitated, etc). Medical documentation of this condition is attached.

___ I have proof that the following person(s) may be involved in this false personation/identity theft (only fill out if you are certain).

_________________________________ _____________________________________

Name (if known) Name (if known)

________________________________ _____________________________________

Address (if known) Address (if known)

_________________________________ _____________________________________

Phone number(s) (if known) Phone number(s) (if known)

_________________________________ _____________________________________

Additional information (e.g. relationship) Additional information (if known)

A report has been made with the following police/sheriff’s department. If you are unable to obtain a report or report number from the police, please indicate that by checking here _____.

Name of agency: _________________________________________________

Name of investigator if known: ______________________________________

Contact information for law enforcement: _____________________________

Report Number: _______________________

Signature of provider of information: _______________________________

Date _______________

I declare under penalty of perjury that this declaration is true and correct to the best of my knowledge. I understand that submitting false information on this affidavit could subject me to criminal prosecution for perjury.

Attachments:

____ Police report - if available

____ Death Certificate (or copy)- required

____ Power of Attorney – if appropriate

____ Proof that requester is Executor or Trustee of estate – if appropriate

____ Proof of relationship – if appropriate

____ Medical documentation.

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Copyright Jan. 2007, Identity Theft Resource Center®, all rights reserved.
Created by ITRC