Fill and Sign the Sworn Statement of Identity Theft Financial Institutions Form

Sworn Statement of Identity Theft Please complete this form and return it to your financial institution with a copy of the police report or the case/offense number from a police department of the reported offense under __________________ (cite appropriate state statute) . If you have not closed all accounts at your financial institutions that were compromised by the reported offense, you should do so immediately. 1. Identification: Name: Mailing Address: City: State: Zip: Phone Number: Home Work: Date of Birth: Driver License Number: State: (If you don’t have a driver license, you must present one of the following forms of government issued identification.)  State Issued Identification State: ID Number:  Military Identification ID Number:  United States Passport ID Number:  Foreign Passport Country: ID Number:  Other – Type: ID Number: 2. Check one. (If you do not attach the police report, you must provide the police case or offense number.)  A copy of the police report is attached to this sworn statement.  A copy of the police report is not attached, but the police case or offense number is: ________________________ and was filed ________________________ (name of law enforcement agency). 3. Identification of accounts at this financial institution that were compromised by the al leged offense: Please list the account numbers of the compromised accounts. Also list the check numbers of any checks that have been lost, stolen, or compromised, if known. Account Number Name(s) on Account Check Number(s) or Range, if Known a. b. c. d. e. f.  Check here if this list is continued on the back of this page. BY SIGNING THIS STATEMENT, YOU ARE:Stating under oath that, to the best of your knowledge and belief, you are the victim of an offense under _____________________ (cite appropriate state statute), relating to the fraudulent, obtaining, transfer, use or possession of your identifying information without your consent;  Requesting that your financial institution close each account identified in Section 3 above; and  Authorizing and requesting that your financial institution submit this information to the electronic notification system. STATE OF _____________ COUNTY OF _________________ Personally appeared before me, the undersigned authority in and for the aforesaid jurisdiction, the within named ______________ (Name of Affiant) who, after having been first duly sworn, stated on oath that the matters and facts set forth in the above and foregoing Petition are true and correct as therein stated. _____________________ (Printed Name of Affiant)_____________________ (Signature of Affiant) SWORN to and subscribed before me, this the ____ day of _____________, 20____. _____________________ Notary Public My Commission Expires: ________________________