Protejase del robo de identidad

Average time to complete: 10 minutes

Identity Theft Victim’s Complaint and Affidavit
A voluntary form for filing a report with law enforcement, and disputes with credit reporting agencies and creditors about identity theft-related problems. Visit ftc.gov/idtheft to use a secure online version that you can print for your records.

Before completing this form: 1. Place a fraud alert on yourcredit reports, and review the reports for signs of fraud. 2. Close the accounts that you know, or believe, have been tampered with or opened fraudulently.

About You (the victim)
Now
(1) (2) (3) (4) (5) My full legal name: ________________________________________________
First Middle Last Suffix Leave (3) blank until you provide this form to someone with a legitimate business need, likewhen you are filing your report at the police station or sending the form to a credit reporting agency to correct your credit report.

My date of birth: __________________
mm/dd/yyyy

My Social Security number: ________-______-__________ My driver’s license: _________
State

___________________
Number

My current street address:____________________________________________________________

________________ Number & Street Name Apartment, Suite, etc.

____________________________________________________________

___
City State Zip Code Country

(6) (7)

I have lived at this address since ____________________
mm/yyyy

My daytime phone: (____)___________________ My evening phone: (____)___________________ My email: ______________________________________

At the Timeof the Fraud
(8) (9) My full legal name was: ____________________________________________
First Middle Last Suffix Skip (8) - (10) if your information has not changed since the fraud.

My address was: _________________________________________________
Number & Street Name State Apartment, Suite, etc. Country

____________________________________________________________

___
City ZipCode

(10)

My daytime phone: (____)_________________ My evening phone: (____)_________________ My email: _____________________________________

The Paperwork Reduction Act requires the FTC to display a valid control number (in this case, OMB control #3084-0047) before we can collect – or sponsor the collection of – your information, or require you to provide it.

Victim’s Name_______________________________ Phone number (____)_________________ Page 2

About You (the victim) (Continued)
Declarations
(11) I did OR did not authorize anyone to use my name or personal information to obtain money, credit, loans, goods, or services — or for any other purpose — as described in this report. receive any money, goods, services, or other benefit as a result of the events described inthis report. willing to work with law enforcement if charges are brought against the person(s) who committed the fraud.

(12) (13)

I I

did am

OR OR

did not am not

About the Fraud
(14) I believe the following person used my information or identification documents to open new accounts, use my existing accounts, or commit other fraud. Name:___________________________________________________
First Middle Last Suffix (14): Enter what you know about anyone you believe was involved (even if you don’t have complete information).

Address: __________________________________________________
Number & Street Name Apartment, Suite, etc.

__________________________________________________________
City State Zip Code Country

Phone Numbers: (____)_______________(____)________________ Additional information about this person: _____________________________________ ____________________________________________________________

___________ ____________________________________________________________

___________ ____________________________________________________________

___________ ____________________________________________________________

___________...