Identity Theft Affidavit and Police Report Cover - District of Columbia

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — DISTRICT OF COLUMBIA

TABLE OF CONTENTS

1. Part A — MPD Police Report Cover Sheet
2. Part B — Sworn Identity Theft Affidavit
3. Part C — Creditor and CRA Dispute Cover Letter
4. Recovery Action Checklist
5. District of Columbia Practice Notes
6. Sources and References

1. PART A — MPD POLICE REPORT COVER SHEET

TO: Metropolitan Police Department of the District of Columbia

Address: [DISTRICT STATION ADDRESS, e.g., First District, 101 M Street SW, Washington, DC 20024]

MPD Online Reporting: https://mpdc.dc.gov/page/file-police-report-online

Citywide Phone (non-emergency): 311 or (202) 727-9099

Statutory Basis for Report. This report is filed in connection with the criminal offense of Identity Theft under D.C. Code § 22-3227.02. The undersigned victim requests that this report be assigned a CCN (Complaint Control Number) and that a copy be provided to the victim for use in invoking the rights provided by the federal Fair Credit Reporting Act, 15 U.S.C. § 1681c-2 (block of information resulting from identity theft), and 15 U.S.C. § 1681g(e) (right to obtain information from creditors).

Penalty Classification (D.C. Code § 22-3227.03). ☐ First Degree (financial injury or property obtained $1,000 or more) ☐ Second Degree (any value, or false accusation/arrest of another) ☐ Unknown at this time.

Brief Narrative. [Concise narrative: when discovered, how discovered, what accounts/identities were misused, suspected method (data breach, mail theft, lost wallet, phishing, family member, etc.).]

[________________________________]

[VICTIM SIGNATURE] Date: [__/__/____]

2. PART B — SWORN IDENTITY THEFT AFFIDAVIT

DISTRICT OF COLUMBIA, ss.:

I, [VICTIM FULL LEGAL NAME], of [ADDRESS], Washington, D.C., being first duly sworn, depose and state:

1. Identity. I am over the age of eighteen, of sound mind, and competent to make this affidavit. The facts stated herein are true and based on my personal knowledge.

2. Personal Identifying Information ("PII"). My PII as defined by D.C. Code § 22-3227.01 includes my name, date of birth, Social Security Number ending in [XXXX], [other identifiers — driver's license number, account numbers, biometric data, medical record numbers], and the financial accounts identified below. I did not authorize any other person to use this PII for any purpose.

3. Date of Discovery. I first discovered the identity theft on or about [__/__/____] when [describe how discovered — credit report, denial of credit, collector contact, IRS notice, breach notification, etc.].

4. Fraudulent Accounts and Activity. The following accounts, transactions, or applications were opened, attempted, or used WITHOUT my knowledge, permission, or authorization:

5. Non-Authorization. I did not open, authorize, ratify, benefit from, or receive any goods, services, or proceeds in connection with the accounts or activity identified in Paragraph 4. I have no business or personal relationship with the perpetrator(s) (or, if the perpetrator is known, see Paragraph 8).

6. Suspect. ☐ The perpetrator is unknown to me. ☐ I suspect or know that the perpetrator is [NAME / RELATIONSHIP], residing at [ADDRESS, if known]. Specifically, [describe basis].

7. Reports Filed. I have:

• ☐ Filed a report with the Federal Trade Commission at IdentityTheft.gov, FTC Identity Theft Report No. [________________________________], on [__/__/____].
• ☐ Filed a police report with the Metropolitan Police Department of the District of Columbia, CCN [________________________________], on [__/__/____].
• ☐ Notified the Internal Revenue Service via Form 14039 (if tax-related). Date: [__/__/____].
• ☐ Notified the Social Security Administration (if SSN misuse). Date: [__/__/____].
• ☐ Notified the U.S. Postal Inspection Service (if mail theft suspected). Date: [__/__/____].
• ☐ Notified each affected creditor or furnisher in writing.
• ☐ Placed an Initial Fraud Alert ☐ Extended Fraud Alert ☐ Security Freeze with each of Equifax, Experian, and TransUnion. Date(s): [__/__/____].

8. Cooperation. I am willing to assist law enforcement in the investigation and prosecution of any person or persons responsible for the identity theft, including providing testimony, exemplar signatures or biometrics, and additional documentation as requested.

9. FCRA Block Request. Pursuant to 15 U.S.C. § 1681c-2, I REQUEST that each consumer reporting agency BLOCK the reporting of all information identified in Paragraph 4 within four (4) business days after receipt of this affidavit and supporting documentation.

10. § 1681g(e) Request to Furnishers. Pursuant to 15 U.S.C. § 1681g(e), I REQUEST that each creditor and furnisher listed in Paragraph 4 provide me, free of charge and within thirty (30) days, copies of all application and business transaction records relating to the fraudulent accounts.

11. Reservation of Civil Remedies. Nothing in this affidavit shall be construed as a waiver of any civil cause of action, including any claim under D.C. Code § 22-3227.05 (civil restitution), the D.C. Consumer Protection Procedures Act (D.C. Code § 28-3905(k) — treble damages or $1,500 per violation, attorney's fees, punitive damages, and injunctive relief), the D.C. Security Breach Protection Act (D.C. Code § 28-3861 et seq.), the federal FCRA, or any other federal or D.C. law.

12. Truthfulness. I declare under penalty of perjury under the laws of the District of Columbia that the foregoing is true and correct.

Executed on [__/__/____] at Washington, D.C.

[________________________________]

[VICTIM PRINTED NAME]

ACKNOWLEDGMENT

Sworn to and subscribed before me this [____] day of [_______________], 20[____], by [VICTIM NAME], who is personally known to me or produced [GOVERNMENT-ISSUED ID TYPE AND NUMBER] as identification.

[________________________________]

Notary Public, District of Columbia

(My Commission Expires: [_______________])

3. PART C — CREDITOR AND CRA DISPUTE COVER LETTER

[VICTIM NAME, ADDRESS, PHONE, EMAIL]

Date: [__/__/____]

VIA U.S. CERTIFIED MAIL — RETURN RECEIPT REQUESTED

Tracking No.: [________________________________]

[CREDITOR / CRA NAME]

Attn: Identity Theft / Fraud Department

[ADDRESS]

Re: Identity Theft Block and Investigation — Account/Reference No. [________________________________]

To Whom It May Concern:

I am a victim of identity theft. The account or item identified above was not opened or authorized by me. Enclosed for your reference and processing are:

• ☐ Exhibit 1 — FTC Identity Theft Report (No. [________________________________]) from IdentityTheft.gov
• ☐ Exhibit 2 — Metropolitan Police Department Report (CCN [________________________________])
• ☐ Exhibit 3 — Sworn Identity Theft Affidavit (notarized)
• ☐ Exhibit 4 — Copy of government-issued photo ID
• ☐ Exhibit 5 — Proof of address (utility bill or lease)

Pursuant to 15 U.S.C. § 1681c-2 (CRAs) and 15 U.S.C. § 1681s-2 (furnishers), I demand that you:

1. Block / cease reporting the fraudulent account or item from my consumer file within four (4) business days (CRAs).
2. Cease all collection activity on the fraudulent account.
3. Provide me, free of charge, copies of all applications and business records relating to the fraudulent account (15 U.S.C. § 1681g(e)) within thirty (30) days.
4. Notify any third party to whom you have furnished information about the fraudulent account that the account is the result of identity theft.
5. Confirm in writing that the account has been blocked/closed/removed and is being reported as such.

I expressly reserve all civil remedies, including without limitation those under the FCRA (15 U.S.C. § 1681n, § 1681o), the D.C. Identity Theft civil action (D.C. Code § 22-3227.05), the D.C. Consumer Protection Procedures Act (D.C. Code § 28-3905(k) — treble damages or $1,500 per violation, attorney's fees, punitive damages, and injunctive relief), and the D.C. Security Breach Protection Act (D.C. Code § 28-3861 et seq.).

Sincerely,

[________________________________]

[VICTIM NAME]

4. RECOVERY ACTION CHECKLIST

• ☐ Pull free credit reports from Equifax, Experian, and TransUnion at AnnualCreditReport.com.
• ☐ File FTC report at IdentityTheft.gov; print recovery plan and Identity Theft Report.
• ☐ File MPD police report online at mpdc.dc.gov or in person; obtain CCN.
• ☐ Notarize this Affidavit.
• ☐ Place Fraud Alert (Initial 1-yr or Extended 7-yr) — only one CRA need be contacted; it will notify the others.
• ☐ Place Security Freeze with all three CRAs (free under D.C. Code § 28-3862).
• ☐ Send Affidavit + reports + ID + proof of address by Certified Mail to each affected creditor/furnisher and to each CRA.
• ☐ Send IRS Form 14039 if tax-related.
• ☐ Notify Social Security Administration if SSN misused.
• ☐ Change all account passwords; enable two-factor authentication.
• ☐ Review medical records (medical identity theft) and request corrections under HIPAA.
• ☐ Calendar 30-day follow-up for FCRA reinvestigation results (15 U.S.C. § 1681i).
• ☐ Preserve every collector communication, account statement, and notice for evidence.
• ☐ Consider consulting an attorney about civil recovery under D.C. Code § 22-3227.05 and the CPPA, especially if a data-breach defendant or negligent furnisher is identifiable.

5. DISTRICT OF COLUMBIA PRACTICE NOTES

• D.C. Identity Theft Statute. D.C. Code § 22-3227.02 makes it a crime to use another's PII to obtain property or to facilitate or conceal a crime. First-degree theft (≥ $1,000) is a felony of up to ten (10) years; second-degree is a misdemeanor (D.C. Code § 22-3227.03).
• Civil restitution. D.C. Code § 22-3227.05 authorizes civil action and restitution, including costs incurred clearing credit, criminal records, and replacing property — recoverable in the criminal case as restitution and in a separate civil action.
• CPPA overlap. Where the defendant is a "merchant" (e.g., a furnisher with sloppy verification practices, a data broker, or a collector pursuing a fraudulent debt), each unlawful trade practice is independently actionable under the CPPA at $1,500 per violation or treble damages, plus attorney's fees and an injunction (D.C. Code § 28-3905(k)).
• Security breach overlay. D.C. Code § 28-3861 et seq. (D.C. Security Breach Protection Act) requires breached entities to notify D.C. residents, and consumers may sue for actual damages plus attorney's fees.
• Free freezes. D.C. residents are entitled to free placement, lifting, and removal of security freezes under D.C. Code § 28-3862.
• FTC Report = sworn affidavit substitute. Under 15 U.S.C. § 1681a(q)(4), an FTC Identity Theft Report functions as the sworn affidavit for blocking. Most CRAs additionally require an MPD police report number; provide both.
• Police-report jurisdiction. File with MPD if you reside in or the theft occurred in the District. If the theft occurred in another jurisdiction, also file there.
• Statute of limitations on civil claim. D.C. Code § 22-3227.05 civil actions follow the general three-year limitation in D.C. Code § 12-301 unless a more specific period applies.
• Children. Special procedures apply under FCRA § 1681c-2A for victims under 16. Freeze the child's file.
• Mail theft. If mail was stolen, file a complaint with the U.S. Postal Inspection Service (uspis.gov).

6. SOURCES AND REFERENCES

• D.C. Code § 22-3227.01 (Definitions) — https://code.dccouncil.gov/us/dc/council/code/sections/22-3227.01
• D.C. Code § 22-3227.02 (Identity theft) — https://code.dccouncil.gov/us/dc/council/code/sections/22-3227.02
• D.C. Code § 22-3227.03 (Penalties) — https://code.dccouncil.gov/us/dc/council/code/sections/22-3227.03
• D.C. Code § 22-3227.05 (Civil action) — https://code.dccouncil.gov/us/dc/council/code/sections/22-3227.05
• D.C. Code § 28-3861 et seq. (Security Breach Protection Act) — https://code.dccouncil.gov/us/dc/council/code/titles/28/chapters/38B
• D.C. Code § 28-3905 (CPPA) — https://code.dccouncil.gov/us/dc/council/code/sections/28-3905
• 15 U.S.C. § 1681c-2 (FCRA blocking) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• MPD Online Reporting — https://mpdc.dc.gov/page/file-police-report-online
• D.C. OAG Identity Theft resources — https://oag.dc.gov/consumer-protection
• AnnualCreditReport.com — https://www.annualcreditreport.com/
• IRS Form 14039 — https://www.irs.gov/forms-pubs/about-form-14039

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Consult a qualified attorney for advice on your specific identity theft circumstances and any potential civil recovery.