IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER

To: [CRA/Furnisher/Financial Institution]
From: [Consumer Name/Address]
Date: [DATE]
DOB: [MM/DD/YYYY]; SSN Last 4: [####]

1. INCIDENT SUMMARY

• I am a victim of identity theft. On or about [DATE], fraudulent accounts/transactions were opened/used without my authorization.
• Fraudulent accounts/transactions: [List creditors, account numbers, dates, amounts].

2. STATEMENT (AFFIDAVIT)

• I did not authorize or benefit from these accounts/transactions.
• I have not given permission to anyone to use my identity for these accounts.
• I request that you block and remove all reporting/collections related to these fraudulent items.

3. DOCUMENTS PROVIDED

• FTC Identity Theft Report (attached).
• Police report filed on [DATE] with [Agency], Report No. [####] (attached).
• Government ID and proof of address.
• Recent CRA report pages highlighting fraudulent items.

4. REQUESTED ACTION

• Block/delete the fraudulent items from my credit file per 15 U.S.C. § 1681c-2; cease collection and notify any third-party collectors.
• Provide written confirmation of actions taken and updated report/account status.
• If you refuse to block/delete, provide a written explanation and any documents relied upon.

Signed (Affidavit):
[Consumer Name]
[Signature]
[Date]

Notary (if required): _________________________