Identity Theft Affidavit Form - Wichita Police Department Page 7
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14Identity Theft Affidavit
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Agency 2
Officer/Agency Personnel Taking Report
Date of Report
Report Number, if any
Telephone Number
Email Address, if any
DOCUMENTATION CHECKLIST
Please indicate the supporting documentation(s) you are able to provide to the companies you
plan to notify. Attach copies (NOT ORIGINALS) to the affidavit before sending it to the companies.
□
20.
A copy of a valid government issued photo identification card, (i.e., driver’s license,
state issued ID Card, passport, etc.). If you are under 16 and do not have a photo ID,
you may submit a copy of your birth certificate or a copy of your official school record
showing your enrollment and place of residence.
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21.
Proof of residency during the time the disputed bill occurred, the loan was made or any
other event took place, (i.e., a rental/lease agreement in your name, a copy of a utility
bill or a copy of an insurance bill).
□
22.
A copy of the report you filed with the police department. If you are unable to obtain a
report or a report number from the police, please indicate in Item 19. Some companies
only need the report number, not a copy of the report; you may want to check with each
company.
CERTIFICATION SIGNATURES
I certify that to the best of my knowledge and belief, all of the information on and attached to this
affidavit is true, correct, complete, and made in good faith. I also understand that this affidavit or
the information it contains may be made available to federal, state and/or local law enforcement
agencies for such action within their jurisdiction as they deem appropriate. I understand that
knowingly making any false or fraudulent statement or representation to the government may
constitute a violation of 18 U.S.C. 1001 or other federal, state or local criminal statutes and may
result in the imposition of a fine, or imprisonment, or both.
Signature
Date signed
Notary
Check with each company. Creditors may require notarization. If they do not, please have one
witness, non-relative, sign below verifying that you completed and signed this affidavit.
Witness:
Signature
Printed name
Date
Telephone number
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