Identity Theft Affidavit Template

Identity Theft Affidavit Template

This Identity Theft Affidavit (“Affidavit”) is made on [Date] by:

Affiant / Victim: [Full Legal Name]
Address: [Address]
Email: [Email]
Phone: [Phone Number]
Date of Birth: [Date of Birth]

1. Identity of Affiant

I, [Full Legal Name], being duly sworn, state that I am the person whose identity or personal information was used without authorization.

My identifying information is as follows:

• Full Legal Name: [Full Name]

• Current Address: [Address]

• Previous Address(es), if relevant: [Previous Address(es)]

• Date of Birth: [Date of Birth]

• Government ID Number, if needed: [Number]

• Last Four Digits of Social Security Number or Other ID Number: [Last Four Digits]

2. Discovery of Identity Theft

I discovered the identity theft on or about [Date].

I became aware of the issue because: [Describe how you learned of the fraud, such as a credit report entry, collection call, denied application, bank alert, IRS notice, or unauthorized transaction].

3. Description of Unauthorized Use

I state that my personal information was used without my knowledge or permission.

The unauthorized use involved the following, to the best of my knowledge:

• ☐ fraudulent credit account

• ☐ unauthorized loan or financing

• ☐ unauthorized bank transaction

• ☐ tax-related identity theft

• ☐ employment-related identity theft

• ☐ utilities or service account fraud

• ☐ medical identity theft

• ☐ other: [Describe]

Additional details:
[Describe what information was misused, such as name, Social Security number, driver’s license number, bank account, credit card, or other data]

4. Fraudulent Accounts or Transactions

The following accounts, applications, or transactions are fraudulent or unauthorized:

Item 1

• Company / Creditor / Institution: [Name]

• Account or Reference Number: [Number]

• Date Opened or Posted, if known: [Date]

• Amount, if known: [Amount]

• Description of Fraud: [Description]

Item 2

• Company / Creditor / Institution: [Name]

• Account or Reference Number: [Number]

• Date Opened or Posted, if known: [Date]

• Amount, if known: [Amount]

• Description of Fraud: [Description]

Item 3

• Company / Creditor / Institution: [Name]

• Account or Reference Number: [Number]

• Date Opened or Posted, if known: [Date]

• Amount, if known: [Amount]

• Description of Fraud: [Description]

Additional fraudulent items: [List as needed or state “None known at this time”]

5. Statement of Non-Authorization

I did not open, apply for, authorize, benefit from, or knowingly participate in the account(s), transaction(s), or activity described in this Affidavit.

To the best of my knowledge, I did not give permission to any person to use my identity or personal information for these purposes.

6. Suspected Method of Identity Theft

To the best of my knowledge, the identity theft may have occurred as follows:

• ☐ lost or stolen wallet, mail, or documents

• ☐ data breach

• ☐ online account compromise

• ☐ phishing or scam

• ☐ stolen card or account information

• ☐ misuse by a known person

• ☐ unknown

• ☐ other: [Describe]

Additional information:
[Describe any known or suspected method]

7. Actions Already Taken

I have taken the following steps in response to the identity theft:

• ☐ contacted the affected company or creditor

• ☐ disputed the fraudulent account or charge

• ☐ placed a fraud alert or security freeze

• ☐ reported identity theft to the FTC

• ☐ filed a police report

• ☐ reported the matter to my bank or card issuer

• ☐ other: [Describe]

Relevant reference numbers, if any:

• FTC Report Number: [Number]

• Police Report Number: [Number]

• Dispute or Claim Number: [Number]

8. Supporting Documents

I may attach copies of documents supporting this Affidavit, including:

• copy of my identification;

• credit report pages showing disputed items;

• account statements or billing notices;

• collection letters;

• police report or case number;

• FTC identity theft report reference;

• transaction records or screenshots;

• other supporting records: [Describe].

9. Request for Reliance

I make this Affidavit for use in investigating and resolving identity theft, correcting records, disputing fraudulent accounts or transactions, and supporting any related claim, dispute, or inquiry.

I request that the recipient reasonably rely on this sworn statement together with any attached supporting documents.

10. Oath and Declaration

I declare under oath and under penalty of perjury that the statements in this Affidavit are true and correct to the best of my knowledge and belief.

11. Signatures

Affiant / Victim

Signature: __________________________
Name: [Full Legal Name]
Date: [Date]

Notary

State of [State]
County of [County]

On [Date], before me, the undersigned notary public, personally appeared [Name of Affiant], known to me or satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed the same for the purposes stated in it.

Notary Public Signature: __________________________
Name of Notary Public: [Full Name]
My Commission Expires: [Date]
Notary Seal: __________________________