Identity Theft Affidavit PDF

Generate a sworn statement that you were a victim of identity theft, including affected accounts and the steps you’ve taken.

Full name

Date of birth

Current address

Phone

Affidavit date

Statement summary

Police report (optional)

I filed a police report about this identity theft

Police report number

Police department

Affected accounts

List every company, bank, or account impacted by the fraud.

Account 1

Company / bank

Account type

Last 4 digits

Date discovered

Fraud description

Disputed amount

I certify under penalty of perjury that the information in this affidavit is true and correct to the best of my knowledge.

Typed signature name

Signature location (optional)

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