INITIAL VICTIM OF IDENTITY THEFT STATEMENT AND
FRAUDULENT ACCOUNT INFORMATION REQUEST
Checking Account Fraud

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

TO:                                                     FAX:                                                            

ACCOUNT NO.                                   REFERENCE NO.                                         

FROM:                                                                                                                    

I have learned that an individual is passing _____ Checks numbered _______to _______ for ____________________(bank name, acct #_____________________) were stolen. Be advised that this account was closed on ____ /_____(date) by the bank upon my request.

_____ Checks have been fraudulently created by another person using my name and address as the account holder

_____ Checks have been fraudulently created by another person using my account number but are not part of my true account. (if appropriate, add if a different name was used)

You are hereby being notified that this is a fraudulent situation and a case of identity theft.

Below is my identifying information. I have filed a report with my local police department. Under CA law (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. According to the Cantwell/Enzi amendment to nationally approved FACTA (effective June 2, 2004) you will be required to comply 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 you may have regarding this situation including video surveillence tape, copies of checks and other transaction records. 

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 this 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.
I am unable in my state to file a police report. Instead per FACTA 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.

___________________________________ ____________________________
Imposter’s true signature   Date

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: