Identity Fraud Affidavit

The identity fraud affidavit can be used to document and communicate facts related to identity theft in order to formally dispute identity fraud and release an identity theft victim’s responsibility for the debt occurred as a result of the identity theft. To ensure a complete documentation and communication of identity fraud cases, a group of credit grantors, consumer advocates, and attorneys at the Federal Trade Commission (FTC) created a document called Identity Theft Affidavit. Although, the identity fraud affidavit was mainly developed to document and communicate facts related to unauthorized new accounts opened under consumer names, the document can also be used to refute charges on existing accounts.

Although, a police report may be sufficient to document an identity theft case, an identity fraud affidavit is a good starting point for documenting all the facts, evidence and witnesses before contacting the police or the affected companies.

The main sections of the identity theft affidavit are listed below which you can copy and paste into an MS Word file to document your case and share with affected companies when needed. Please remember that you should not send this form to the FTC or any other government agency. The FTC does mediate and resolve disputes between parties.

My full legal name is ______________________

My date of birth is ____-__-____ (day/month/year)

My Social Security number is ______-____-______

My driver’s license or identification card state and number are


My current address is _______________________________________________________________

City ______________________ State ____________ Zip Code _______

I have lived at this address since _________________ (month/year)

If different from above), when the events described in this affidavit took place,

my address was_____________________________City _______________

State _________________ Zip Code ________

My daytime telephone number is (_____)________________ My evening telephone number 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 (for example, credit cards; birth certificate; driver’s license; Social Security card; etc.) were stolen or lost (circle all that apply) on or about ________________________. (day/month/year)

----To the best of my knowledge and belief, the following person(s) used my information (circle all that apply - my name, address, date of birth, existing account numbers, Social Security number, mother’s maiden name, etc.) or the following identification documents (-------------------------------------) to get money, credit, loans, goods or services without my knowledge or authorization:

Name (if known)_______________________________________

Address (if known)____________________________________

Phone number(s) (if known)____________________________ Additional information (if known)


----I do NOT know who used my information or identification documents to get money, credit, loans, goods or services without my knowledge or authorization.

Additional comments: (For example, description of the fraud, which documents or information were used or how the identity thief gained access to your information.) _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Attach additional pages as necessary.)

Victim’s Law Enforcement Actions (check one)

----I am not willing to assist in the prosecution of the person(s) who committed this fraud.

----I am not authorizing the release of this information to law enforcement for the purpose of assisting them in the investigation and prosecution of the person(s) who committed this fraud.

----I have not reported the events described in this affidavit to the police or other law enforcement agency.

----I have reported the event to the police or other law enforcement agency, please complete the following:

(Agency #1) _________________________________________________

(Date of report)(Report number, if any)______________________

(Phone number)(email address, if any)________________________

(Agency #2)__________________________________________________

(Date of report)(Report number, if any) _____________________

(Phone number)(email address, if any)________________________

Please indicate the supporting documentation you are able to provide to the companies you plan to notify. Attach copies (NOT originals) to the identity fraud affidavit before sending it to the companies. Examples of documents to be attached include:

---- A copy of a valid government-issued photo-identification card (for example, your driver’s license, state-issued ID card or your passport). If you are under 16 and don’t have a photo-ID, you may submit a copy of your birth certificate or a copy of your official school records showing your enrollment and place of residence.

---- Proof of residency during the time the disputed bill occurred, the loan was made or the other event took place (for example, a rental/lease agreement in your name, a copy of a utility bill or a copy of an insurance bill.

---- A copy of the report you filed with the police or sheriff’s department if accepted by the companies you plan to contact. Check with each company.


Date signed ____________________

Creditors sometimes require notarization. If they do not, please have one witness (non-relative) sign below to confirm that "you" completed and signed this identity fraud affidavit. Check with each company first.

Witness Name: ________________________________________

Witness signature: ___________________________________

Date signed: _________________________________________

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