Nicor Gas Fraud Affidavit

ID Theft Affidavit

Instructions for Completing the ID Theft Affidavit

To make certain that you do not become responsible for any debts incurred by an identity thief, you must prove to each of the companies where accounts were opened or used in your name that you didn’t create the debt.

A group of credit grantors, consumer advocates, and attorneys at the Federal Trade Commission (FTC) developed an ID Theft Affidavit to make it easier for fraud victims to report information.

Nicor Gas Company utilizes this form and in addition requires a copy of a police report, proof of residency during disputed time frame and a copy of a photo I.D. to be attached to your submission.

This affidavit has two parts: Part One is the ID Theft Affidavit, where you report general information about yourself and the theft. Part Two is the Fraudulent Account Statement, where you describe the fraudulent account(s) opened in your name.

Victim Information

(1) My full legal name is

(2) If different from above, when the events described in this affidavit took place, I was known as

(3) My date of birth is

(4) My Social Security number is

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

(6) My current address is

City State Zip Code

(7) I have lived at this address since

(8) If different from above, when the events described in this affidavit took place, my address was

City State Zip Code

(9) I lived at the address in Item 8 from until

(10) My daytime telephone number is My evening telephone number is

How the Fraud Occurred

(11) 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.

(12) I did not receive any benefit, money, goods or services as a result of the events described in this report.

(13) My identification documents were stolen lost on or about

(14) To the best of my knowledge and belief, the following person(s) used my information or identification documents without my knowledge or authorization:

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

(16) Additional comments:

Victim’s Law Enforcement Actions

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

(18) am authorizing 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.

(19) have have not reported the events described in this affidavit to the police or other law enforcement agency. The police did did not write a report.

Documentation Checklist

(20) A copy of a valid government-issued photo-identification card.

(21) Proof of residency during the time the disputed bill occurred, the loan was made or the other event took place.

(22) A copy of the report you filed with the police or sheriff’s department.

Signature

I certify that, to the best of my knowledge and belief, all the information on and attached to this affidavit is true, correct, and complete and made in good faith.

Fraudulent Account Statement

Completing this Statement

Make as many copies of this page as you need. Complete a separate page for each company you’re notifying and only send it to that company. Include a copy of your signed affidavit.

I declare (check all that apply):

As a result of the event(s) described in the ID Theft Affidavit, the following account(s) was/were opened at your company in my name without my knowledge, permission or authorization using my personal information or identifying documents:

During the time of the accounts described above, I had the following account open with your company:

Billing name

Billing address

Account number