Letter Form 100 - 1 Initial Victim of Identity Theft Statement and Fraudulent Account Information Request to Credit Issuers or Merchants

Please Send this letter form to the Credit Issuers or Merchants who appear on your credit report. For more information please read our Fact Sheet 100  The Begining Steps

Do not send letter forms or documents to the Identity Theft Resource Center as we cannot clear your record for you of fraudulent information.

INITIAL VICTIM OF IDENTITY THEFT STATEMENT AND
FRAUDULENT ACCOUNT INFORMATION REQUEST 
 Credit Issuers or Merchants

Date:______________
Sent certified, return receipt mail:  Number ______________________

TO :                    [Credit Issuer]                     FAX                                                   

ACCOUNT NO.                                           REFERENCE NO.                                

FROM:       [Your Name]                                                                                      

I have learned that an unauthorized account has been opened with your company or bank. I did not open this account and have not given permission to anyone else to open this account for me. I have not benefited by this account. You shall consider this account to be fraudulent and a case of identity theft.

Below is my identifying information. I have filed a report with my local police department. Under CA (PC 530.8) and WA law, all lenders and credit issuers must provide documentation regarding all fraudulent accounts opened in another’s identity and do so within ten days. The Cantwell-Enzi amendment to the nationally approved FACTA (effective June 2, 2004) will require compliance with this request within 30 days.

Further, credit issuers must provide that documentation and information to a police agency designated by the impersonated party. I am designating the below named detective(s)/prosecutors as additional recipients of all account information and documents:

• Application Records or screen prints of Internet/phone applications
• Statements, Billing and Payment Records
• Transaction Records/Charge Slips
• Log of outgoing calls if a cell phone account or telephone utility
• Investigator’s Summary
• Delivery addresses
• Any other documents associated with the account
• All records of phone numbers used to activate the account or to access the account

Additionally, I hereby request you immediately start an investigation, and remove any entries of this account, the application or inquiry records and collection notices from my credit report at once. I also wish to speak with a fraud investigator within 30 days about the status of this case. Once resolved, I expect a letter of clearance to be sent to me within 10 days.

Do not sell, distribute, trade, exchange, share, donate, giveaway and/or transfer information about this fraudulent account with any other entity except with the designated law enforcement agencies and prosecutors involved in this case.

Please notify any collection agencies that you may have sent this account to. Please do not assign this account to another collection agency. So far these criminals have stolen approximately  $_______ in checks or credit charges in my name. We suspect there will be more until they are caught.

Be advised that reporting these items to the credit bureaus as collection items or continuing to pursue these debts from me would be considered a violation of the state and federal level Fair Debt Collection Practices Act and the Fair Credit Reporting Act.  

Victim Information

1.   My full legal name is:________________________________ 
 
 (If different from above) When the events described in this affidavit took place, I was known as: ________________________________________

2. My birth date is (day/month/year): ____________________

3. My Social Security number is________________________________

4. My driver’s license or identification card number is: State________  #________________

5. My current address is: ________________________________________________________

City:  ___________________________  State:_________________Zip Code:____________

6. I have lived at this address since _____________________________(month/year)

7. (If different from above) When the events described in this affidavit took place, my address was: ________________________________________________________

City:  ____________________________  State:_________________Zip Code:_________

8. I lived at that address from __________ until __________(month/year)

9. My daytime telephone number is (____)___________________ 
                                              Cell (____) __________________

10. My evening telephone number is (____)___________________

11.  My e-mail address is  ______________________________

How the Fraud Occurred  (Check all that apply):

___ 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.

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

___ My identification documents (ie., credit cards; birth certificate; driver's license; Social Security card, etc.)  were stolen   were lost on or about _____________(day/month/year)

___ I don’t know who the imposter is at this time or how this happened. 

___ I have proof that 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 obtain money, credit, loans, goods, or services without my knowledge or authorization: (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 _____. Instead of a police report I filed an official affidavit with the following agency ___________________ (case #________) 

Name of agency: _________________________________________________
Case #__________________________________________________________
Name of investigator if known: ______________________________________
Contact information for law enforcement: (address/phone)________________
_______________________________________________________________

Signature of victim:  _______________________________   Date _______________

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

Have one witness (non-relative) sign below that you completed and signed this declaration.)

Witness:

___________________________________     __________________________________
(signature)                                                      (printed name)

_________________________                       _________________________________
(date)                                                             (telephone number)

List of enclosed documents: