Compromised Identity Review Claim Form - Florida Department Of Law Enforcement

Florida Department of Law Enforcement

Compromised Identity Review Claim Form

FOR FDLE USE ONLY

Disclaimer: This form is used for criminal record information only

Case #: _________

***Please be sure to print this form on legal 8.5” x 14” paper***

______

Member:

*This form must be mailed to FDLE by the law enforcement agency that completes the fingerprint portion below*

1.

Your Full Name (include maiden or other names used): __________________________________________________________

__________________________________________________________

2.

Date of Birth: ______________ Driver’s License Number (optional): _________________________

Sex: _______ Race: ________ SSN (optional): ____________________

FDLE asks that you provide your SSN. The decision to provide your SSN is at your option, and if you provide your SSN, FDLE will use it for purposes of identification, and may

share the information with other agencies for the same purpose. FDLE’s request for your SSN is authorized by state law because use of it is imperative for FDLE to fulfill its lawful

duties and responsibilities. Your failure to provide your SSN may result in a delay in processing your application or request.

3.

Current Mailing Address: __________________________________________________________________________________

Email Address: __________________________________________________________________________________________

4.

Current Phone Number: ____________________________ Alternate Phone Number: _________________________________

5.

Have you previously completed a personal review with the FDLE? _________ If so, what was your case number? ___________

6.

What event made you believe that your identity was used in an arrest record:

Employment

Traffic Stop

Housing

Theft/Loss

Other: ____________________

7.

If known, please include the following information regarding the possible true offender:

Full Name (include maiden or other names used): _______________________________________________________________

Date of Birth: ________________ SSN (optional): __________________________ Sex: ___________ Race: ____________

Last known address: _______________________________________________________________________________________

8.

If you are aware of how your identity was obtained briefly describe: ________________________________________________

________________________________________________________________________________________________________

9.

If known please indicate which part of your identity was used:

Date of Birth

SSN

Name

All of these

10. Was the possible offender:

A Relative

An Acquaintance/Friend

A Stranger

Unknown

Other: _____________

11. Along with this form, please provide any additional information or documentation (i.e. court or law enforcement documents) that may

support your claim.

12. Although the following items are not required, the FDLE would ask that you supply a photocopy of your Driver’s License and Social

Security card along with this claim form to expedite the resolution of your case.

***Law Enforcement Officer or Agency Designee: Please verify identity information above against a photo ID.

Please mail completed form in your official agency envelope to:

FDLE, P.O. Box 1489, Tallahassee, FL 32302, Attn: Quality Control Section, Compromised ID***

Signature of official taking fingerprints: _____________________________________ ORI: ________________________________

By signing this form I hereby attest that I believe I may be a victim of identity theft and/or have had my personal identification information stolen or misused in the past.

Signature of person fingerprinted: ________________________________ Date: ________________________________________

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