Identity Theft Affidavit and Police Report Cover - Connecticut

IDENTITY THEFT AFFIDAVIT AND POLICE-REPORT COVER PACKET — CONNECTICUT

PART A — POLICE-REPORT COVER LETTER

Date: [__/__/____]

To:

[NAME OF CONNECTICUT POLICE DEPARTMENT — e.g., Hartford Police Department, Records Division]

[ADDRESS]

[CITY, CT ZIP]

Re: Request for Identity-Theft Police Report — Conn. Gen. Stat. § 53a-129a et seq.

Dear Records Officer:

I am the victim of identity theft. I respectfully request that the Department accept this written report and issue an official police report (also known as an "identity-theft report") so that I may invoke the protections of the federal Fair Credit Reporting Act (15 U.S.C. § 1681c-2) and Connecticut law (Conn. Gen. Stat. § 53a-129a et seq.).

Enclosed is my sworn Identity Theft Affidavit (Part B), together with copies of the supporting documents listed at the end of this packet (Part D). I will sign this report under oath and supplement it with any additional information the Department requires.

I respectfully request that the Department:

1. Document the offense as a Connecticut state crime under the appropriate degree pursuant to Conn. Gen. Stat. §§ 53a-129b, 53a-129c, or 53a-129d (and § 53a-129e if trafficking in personal identifying information is involved);
2. Provide me with a free copy of the official report bearing a case or incident number;
3. Refer the matter to the relevant detective division or the Connecticut Financial Crimes Task Force as appropriate;
4. Coordinate as needed with the Office of the Attorney General, the Connecticut Department of Consumer Protection, the FBI's Internet Crime Complaint Center (IC3), the U.S. Secret Service (for credit and access-device fraud), and the Federal Trade Commission (IdentityTheft.gov).

I have made or will make a complementary report at www.IdentityTheft.gov (FTC Identity Theft Report Number: [__________________], if available).

Thank you for your prompt assistance.

Respectfully,

[________________________________]

[VICTIM FULL LEGAL NAME]

[TELEPHONE] | [EMAIL] | [MAILING ADDRESS]

PART B — IDENTITY THEFT AFFIDAVIT

STATE OF CONNECTICUT

COUNTY OF [______________________]

I, [VICTIM FULL LEGAL NAME], being duly sworn, depose and say:

B.1 Personal Information

B.2 Discovery of the Theft

B.2.1. I first discovered that I was a victim of identity theft on or about [__/__/____] when I [describe — received a collection call, opened a credit report, received a denial of credit, found unauthorized charges, received tax notice, etc.].

B.2.2. To the best of my knowledge, the unauthorized use began on or about [__/__/____].

B.2.3. I did not authorize and did not benefit from any of the transactions, accounts, or activity described below. I have never received any goods, services, money, credit, or property from the fraudulent transactions.

B.3 Suspected Perpetrator (if known)

B.4 Fraudulent Accounts and Transactions

The following accounts, charges, or transactions were opened or made WITHOUT my consent:

B.5 Documents Affected (check all that apply)

• ☐ Credit / debit card (lost, stolen, or compromised)
• ☐ Social Security Card / Number
• ☐ Connecticut Driver's License or State ID
• ☐ U.S. Passport
• ☐ Birth certificate
• ☐ Bank account / checks
• ☐ Tax filing (federal or Connecticut)
• ☐ Unemployment / benefits filing
• ☐ Medical insurance card
• ☐ Other: [__________________]

B.6 Steps Taken

I have taken the following steps to protect myself:

• ☐ Filed a report at IdentityTheft.gov (FTC Report No. [__________________])
• ☐ Placed a fraud alert with the three nationwide credit bureaus
• ☐ Placed a credit freeze (Conn. Gen. Stat. § 36a-701a) with [Equifax / Experian / TransUnion]
• ☐ Filed this report with [POLICE DEPT] (Case No. [__________________])
• ☐ Notified the affected creditors and account-issuing institutions
• ☐ Closed compromised accounts
• ☐ Changed online passwords and enabled multi-factor authentication
• ☐ Notified the IRS (Form 14039) and CT Department of Revenue Services (855-842-1441)
• ☐ Notified the Social Security Administration (1-800-269-0271)
• ☐ Other: [__________________]

B.7 Affirmation

I declare under penalty of perjury under the laws of the State of Connecticut and the United States of America that the foregoing is true and correct to the best of my knowledge, information, and belief. I make this affidavit for the purposes of:

(a) reporting a crime to law enforcement under Conn. Gen. Stat. § 53a-129a et seq.;

(b) constituting an "identity theft report" within the meaning of 15 U.S.C. § 1681a(q) and 16 C.F.R. § 603.3 to invoke FCRA blocking under 15 U.S.C. § 1681c-2; and

(c) requesting business records from creditors and merchants under 15 U.S.C. § 1681g(e).

Executed at [CITY, COUNTY], Connecticut, on [__/__/____].

[________________________________]

[VICTIM NAME]

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public / Commissioner of the Superior Court

(My commission expires: [_______________])

PART C — FCRA BLOCK-AND-DISPUTE DEMAND (TO CRAs AND FURNISHERS)

Date: [__/__/____]

To:

☐ Equifax Information Services LLC, P.O. Box 105069, Atlanta, GA 30348

☐ Experian, P.O. Box 9554, Allen, TX 75013

☐ TransUnion LLC Consumer Dispute Center, P.O. Box 2000, Chester, PA 19016

☐ Furnisher: [NAME], [ADDRESS]

Re: Identity-Theft Block and Dispute — 15 U.S.C. § 1681c-2 and § 1681i

Consumer: [NAME] | DOB [__/__/____] | Last 4 SSN [XXXX] | Address [ADDRESS]

Dear Sir or Madam:

I am a victim of identity theft. Pursuant to 15 U.S.C. § 1681c-2, I demand that you BLOCK the reporting of any information in my consumer file that is the result of identity theft, within four (4) business days of receipt. The fraudulent items are listed in the enclosed Identity Theft Affidavit (Part B) and police report (Part A).

Enclosed are the items required by 15 U.S.C. § 1681c-2(a):

1. Appropriate proof of identity (15 U.S.C. § 1681c-2(a)(1)) — copy of [Connecticut Driver's License / State ID / utility bill / Social Security Card];

2. A copy of an identity theft report (15 U.S.C. § 1681c-2(a)(2)) — see enclosed police report and FTC report from IdentityTheft.gov;

3. The identification of information by me alleged to be a result of identity theft (15 U.S.C. § 1681c-2(a)(3)) — itemized in Part B, § B.4; and

4. A statement by me that the information is not information relating to any transaction by me (15 U.S.C. § 1681c-2(a)(4)) — see Part B, ¶ B.2.3.

I additionally dispute these items pursuant to 15 U.S.C. § 1681i and demand reinvestigation. Please flag the disputed items in any subsequent reporting per 15 U.S.C. § 1681e and § 1681i(c). To furnishers: please cease furnishing the disputed information per 15 U.S.C. § 1681s-2(a)(6).

Please send written confirmation of compliance to the address above within thirty (30) days. Failure to comply will give rise to claims for actual and statutory damages, attorney's fees, and (for willful violations) punitive damages under 15 U.S.C. § 1681n and § 1681o, as well as state-law claims under the Connecticut Unfair Trade Practices Act, Conn. Gen. Stat. § 42-110a et seq.

Sincerely,

[________________________________]

[VICTIM NAME]

PART D — ENCLOSURES CHECKLIST

• ☐ Identity Theft Affidavit (Part B, sworn and notarized)
• ☐ Police-Report Cover Letter (Part A)
• ☐ FTC IdentityTheft.gov Report / Recovery Plan
• ☐ Photo identification (Connecticut Driver's License / State ID / U.S. Passport)
• ☐ Proof of address (utility bill / lease / mortgage statement)
• ☐ Copies of fraudulent account statements or letters
• ☐ Credit reports from Equifax, Experian, and TransUnion (current within 30 days)
• ☐ Correspondence with creditors / banks / collectors
• ☐ Power of attorney (if represented by counsel)

PART E — REQUESTS FOR BUSINESS RECORDS UNDER 15 U.S.C. § 1681g(e)

To: [CREDITOR / MERCHANT NAME AND ADDRESS]

Pursuant to 15 U.S.C. § 1681g(e), I, [VICTIM NAME], request copies of all application and business transaction records, including any documents bearing my name, address, Social Security Number, or signature, in connection with account / transaction [ACCOUNT NUMBER]. Records must be provided free of charge within thirty (30) days. Enclosed is proof of identity and a copy of the police report or sworn affidavit, satisfying the verification requirements of § 1681g(e)(2).

Direct response to: [VICTIM ADDRESS] with copies to [POLICE DEPT — CASE NO.].

[________________________________]

[VICTIM NAME]

PART F — CONNECTICUT PRACTICE NOTES

• Criminal classification. Conn. Gen. Stat. §§ 53a-129b through 53a-129d grade identity theft by victim age (60+) and value of property obtained: First Degree (Class B felony — over $10,000 or victim 60+ with over $5,000); Second Degree (Class C — over $5,000); Third Degree (Class D — all other cases). Trafficking in personal identifying information is a Class D felony under § 53a-129e.
• Credit freeze (free). Connecticut residents may place a security freeze on their consumer credit reports at no cost — Conn. Gen. Stat. § 36a-701a (now harmonized with the federal Economic Growth, Regulatory Relief, and Consumer Protection Act, which made freezes free nationwide).
• Data breach notification. If an entity disclosed your data through a breach, see Conn. Gen. Stat. § 36a-701b — Connecticut requires notice "without unreasonable delay" and not later than 60 days after discovery.
• CUTPA overlay. Failure of a merchant to maintain reasonable security or to assist a victim may constitute an unfair or deceptive practice under CUTPA, Conn. Gen. Stat. § 42-110a et seq., with private right of action under § 42-110g.
• Statutes of limitations. FCRA private actions: the earlier of 2 years after discovery or 5 years after the violation (15 U.S.C. § 1681p). Connecticut tort claims for invasion of privacy / intentional misconduct generally three years (Conn. Gen. Stat. § 52-577); CUTPA three years (§ 42-110g(f)).
• Tax-related identity theft. File IRS Form 14039 (Identity Theft Affidavit). For Connecticut state tax issues, contact the CT Department of Revenue Services Fraud Prevention Unit at 855-842-1441.
• Government-issued ID compromise. If your CT Driver's License or State ID is compromised, contact the CT DMV Fraud Investigations Unit at 860-263-5202 to request a flag on your record.
• Specialty CRAs. Send Part C to specialty consumer reporting agencies that may report on you (e.g., LexisNexis Risk Solutions, ChexSystems, MIB Group, Innovis) — required under 15 U.S.C. § 1681c-2.

PART G — SOURCES AND REFERENCES

• Conn. Gen. Stat. Title 53a, Chapter 952 (Penal Code — Identity Theft) — https://www.cga.ct.gov/current/pub/title_53a.htm
• Conn. Gen. Stat. § 36a-701a (Security Freeze) and § 36a-701b (Data Breach Notification)
• Conn. Gen. Stat. Chapter 735a (CUTPA) — https://www.cga.ct.gov/current/pub/chap_735a.htm
• 15 U.S.C. § 1681 et seq. (FCRA) — https://www.law.cornell.edu/uscode/text/15/chapter-41/subchapter-III
• 16 C.F.R. § 603.3 (FTC — Identity Theft Report Definition)
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• IRS Identity Protection — https://www.irs.gov/identity-theft-fraud-scams
• CT Department of Revenue Services — Tax-Related Identity Theft — https://portal.ct.gov/DRS/Fraud/Tax-Related-Id-Theft/ID-Theft
• CT Attorney General — Privacy & Data Security — https://portal.ct.gov/ag/sections/privacy/privacy-task-force
• CT Department of Consumer Protection — https://portal.ct.gov/dcp
• CT Judicial Branch — Law About Identity Theft — https://www.jud.ct.gov/lawlib/law/identitytheft.htm

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Connecticut should review and customize this packet before reliance, particularly for any related civil litigation. Statutes and regulations change frequently; verify all authorities before use.