Identity Theft Affidavit and Police Report Cover (Hawaii)

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — HAWAII

TABLE OF CONTENTS

1. Cover Sheet to Hawaii Law Enforcement
2. Identity Theft Affidavit
3. Schedule A — Fraudulent Accounts and Charges
4. Schedule B — Affected Creditors and Furnishers
5. Notarial Acknowledgment
6. FCRA Block / Dispute Demand to Consumer Reporting Agencies
7. Furnisher Notice and Request for § 1681g(e) Records
8. Hawaii Practice Notes
9. Sources and References

1. COVER SHEET TO HAWAII LAW ENFORCEMENT

To: [HONOLULU POLICE DEPARTMENT / HAWAII COUNTY POLICE DEPARTMENT / MAUI POLICE DEPARTMENT / KAUAI POLICE DEPARTMENT]

Attn: Records Division / Financial Crimes Unit

[STATION ADDRESS]

Date: [DATE]

Re: Request to file police report for Identity Theft pursuant to Haw. Rev. Stat. §§ 708-839.6 through 708-839.8.

I am the victim of identity theft and request that this matter be documented in an official police report. The attached sworn Identity Theft Affidavit summarizes the facts. I will cooperate with any investigation and can be contacted at the address and number above.

I respectfully request:

• ☐ Issuance of a police report case number;
• ☐ A stamped or certified copy of the police report (or face-page summary) for use in disputing fraudulent accounts under the federal Fair Credit Reporting Act, 15 U.S.C. § 1681c-2;
• ☐ Referral to the appropriate Financial Crimes / Identity Theft investigator if charges are warranted under HRS §§ 708-839.6, 708-839.7, or 708-839.8.

Respectfully,

[________________________________]

[VICTIM NAME]

Police Report Case No. (assigned): [________________________________]

Officer Name and Badge: [________________________________]

Date Filed: [__/__/____]

2. IDENTITY THEFT AFFIDAVIT

STATE OF HAWAII

COUNTY OF [__________]

I, [VICTIM FULL LEGAL NAME], being first duly sworn upon oath, depose and state:

2.1. I am over the age of eighteen (18), competent to testify, and have personal knowledge of the matters stated herein.

2.2. I reside at [STREET, CITY, HI ZIP], and I have resided in the State of Hawaii since [DATE].

2.3. My date of birth is [__/__/____], and the last four digits of my Social Security number are [####].

2.4. I did not authorize, consent to, or benefit from the accounts, charges, or transactions described in Schedule A. Each was opened or made by an unknown person or persons using my personal identifying information without my permission.

2.5. I first discovered the identity theft on or about [__/__/____] when [DESCRIBE — e.g., I received a collection letter, a credit-report alert, a denial of credit, a tax-refund rejection, a notice from law enforcement].

2.6. I do not know the perpetrator, [OR] I believe the perpetrator may be [NAME / RELATIONSHIP], based on [BASIS]. [Strike whichever does not apply.]

2.7. I have not given anyone permission to use my name, Social Security number, date of birth, driver's license number, financial-account numbers, or other personal information to open accounts, obtain credit, lease property, or conduct any transaction.

2.8. The fraudulent accounts and transactions are itemized in Schedule A. The creditors and furnishers reporting these items are listed in Schedule B.

2.9. I have filed (or will file contemporaneously):

• ☐ A report with the U.S. Federal Trade Commission at IdentityTheft.gov, Report No. [________________________________];
• ☐ A police report with the [Honolulu / Hawaii County / Maui / Kauai] Police Department, Case No. [________________________________];
• ☐ A complaint with the Hawaii Department of Commerce and Consumer Affairs, Office of Consumer Protection;
• ☐ Disputes and FCRA § 1681c-2 block requests with Equifax, Experian, and TransUnion;
• ☐ Direct dispute notices with each affected furnisher under 15 U.S.C. § 1681s-2(a)(8) and § 1681g(e).

2.10. I request that the enclosed ☐ FTC Identity Theft Report from IdentityTheft.gov or ☐ sufficiently specific official police report be treated as an "Identity Theft Report" within the meaning of 12 C.F.R. § 1022.3(i) and 15 U.S.C. § 1681a(q)(4), with this affidavit serving as supporting documentation.

2.11. I declare under penalty of perjury under the laws of the State of Hawaii (Haw. Rev. Stat. § 710-1062) and of the United States of America that the foregoing is true and correct.

Executed on [__/__/____] at [CITY], Hawaii.

[________________________________]

[VICTIM SIGNATURE]

[PRINTED NAME]

3. SCHEDULE A — FRAUDULENT ACCOUNTS AND CHARGES

4. SCHEDULE B — AFFECTED CREDITORS AND FURNISHERS

For a freeze, contact all three consumer reporting agencies through the FTC's
current directory. For an alert, follow the current one-agency referral route.
Verify the recipient and submission channel immediately before sending:
https://consumer.ftc.gov/articles/credit-freezes-and-fraud-alerts.

5. NOTARIAL ACKNOWLEDGMENT

STATE OF HAWAII

COUNTY OF [__________]

On this [____] day of [_______________], 20[____], before me personally appeared [VICTIM NAME], who is personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument, and who acknowledged that he/she executed the same as his/her free and voluntary act.

[________________________________]

Notary Public, State of Hawaii

(Print Name): [_______________]

My commission expires: [__/__/____]

(Notarial seal/stamp)

6. FCRA BLOCK / DISPUTE DEMAND TO CONSUMER REPORTING AGENCIES

To: [Equifax / Experian / TransUnion]

Pursuant to 15 U.S.C. § 1681c-2 (FCRA § 605B), I demand that the consumer reporting agency BLOCK the reporting of the items listed in Schedule A within four (4) business days of receipt of this Identity Theft Report. Enclosed are:

• ☐ Sworn Identity Theft Affidavit (notarized);
• ☐ FTC Identity Theft Report from IdentityTheft.gov (Report No. [____]);
• ☐ Police Report from [POLICE DEPARTMENT] (Case No. [____]);
• ☐ Government-issued photo identification (last 4 of SSN: [####]);
• ☐ Proof of current residence address.

I further request, pursuant to 15 U.S.C. § 1681g(a), a free copy of my consumer file, and pursuant to 15 U.S.C. § 1681c-1, the placement of:

• ☐ An extended fraud alert (7 years) under § 1681c-1(b); OR
• ☐ A free security freeze under § 1681c-1(i).

Refusal to block within the statutory four-day window, or reinsertion without statutory grounds, will be treated as a willful FCRA violation actionable under 15 U.S.C. §§ 1681n and 1681o.

[________________________________]

[VICTIM NAME]

Date: [__/__/____]

7. FURNISHER NOTICE AND REQUEST FOR § 1681g(e) RECORDS

To: [FURNISHER NAME]

Attn: Fraud / Identity Theft Department

Complete the delivery and documentation gates before sending. These are separate statutory routes; satisfying one does not automatically satisfy the other.

• ☐ This notice is being sent to the address the furnisher specified for identity-theft reports.
• ☐ The enclosed identity theft report states that the identified information resulted from identity theft.
• ☐ Any direct dispute separately identifies the specific information, explains the basis, and includes the support required at the furnisher's designated dispute address.
• ☐ Any consumer-reporting-agency dispute has been filed separately; § 1681s-2(b) duties arise after the furnisher receives the agency's notice under § 1681i(a)(2).

Under 15 U.S.C. § 1681s-2(a)(6)(B), I request that you not furnish the identified information to a consumer reporting agency unless you subsequently know, or I inform you, that it is correct. This request relies on the identity theft report and designated-address facts checked above; it is not a generic collection cease-and-desist.

Separately, under 15 U.S.C. § 1681g(e), I request, without charge, copies of application and business-transaction records in your control that evidence the transactions identified below. This written request is mailed to the address you specified for such requests and includes the available transaction date and account or transaction number.

Enclosures for the § 1681g(e) verification process:

• ☐ Government-issued identification or other identifying material selected by the business under § 1681g(e)(2)(A);
• ☐ Police report evidencing the identity-theft claim; and
• ☐ Properly completed standardized identity-theft affidavit or other affidavit acceptable to the business.

Subject to the statute's identity-and-claim verification, scope, good-faith decline, and record-availability provisions, responsive records are due within thirty (30) days after receipt of a qualifying request. The section does not require creation or retention of records that the business does not otherwise maintain.

The disputed account(s):

This request does not assume that every statutory duty creates a private damages claim. Sections 1681s-2(c)-(d) limit private liability and enforcement for subsection (a), and § 1681g(e)(6) limits FCRA liability for that subsection. Counsel should classify any furnishing, collection, or Hawaii UDAP claim under its own elements and enforcement provision.

[________________________________]

[VICTIM NAME]

Date: [__/__/____]

8. HAWAII PRACTICE NOTES

• State criminal hooks. Hawaii grades identity theft into three degrees by intent and value: HRS § 708-839.6 (first degree, Class A — to facilitate murder, kidnapping, extortion, etc.); HRS § 708-839.7 (second degree, Class B — to commit theft of property in the first or second degree); HRS § 708-839.8 (third degree, Class C — to commit theft in the third or fourth degree). All three are felonies; document loss amounts carefully.
• Police filing. Hawaii has four county police departments (Honolulu, Hawaii, Maui, Kauai). Follow the receiving agency's current procedure and retain the report number or face sheet. A qualifying identity theft report is required for an FCRA § 1681c-2 block, but that report is not categorically limited to a police report; a business may separately require a police report and acceptable affidavit under § 1681g(e).
• Identity Theft Report. Under 12 C.F.R. § 1022.3(i), an FTC Identity Theft Report created through IdentityTheft.gov or a sufficiently specific official police report may qualify; the two are not categorically required as a combined package. A qualifying report and the other materials required by FCRA § 1681c-2 support blocking within four business days, while § 1681g(e) separately governs record requests.
• Security freeze. A federal security freeze under 15 U.S.C. § 1681c-1(i) is free in all states (post-Economic Growth Act 2018). This template requests it; a freeze is generally stronger than a fraud alert.
• Hawaii data-breach overlay. If the underlying compromise stems from a Hawaii business breach, HRS ch. 487N requires consumer notification and reporting to the DCCA Office of Consumer Protection. Preserve breach notice letters as evidence.
• DCCA OCP complaint. Filing a parallel complaint with the Office of Consumer Protection at 235 S. Beretania St., Suite 801, Honolulu, HI 96813, can support investigation of unlicensed or abusive collectors who continue dunning the victim.
• Tax-refund ID theft. If the fraud involves a fraudulent tax return, also file IRS Form 14039 only if current IRS instructions call for it and contact the Hawaii Department of Taxation; tax-related ID theft is excluded from the FTC IdentityTheft.gov flow's full record-pull authority.
• Medical ID theft. If healthcare accounts are involved, also file a HIPAA accounting-of-disclosures request with the affected provider and notify the U.S. Department of Health and Human Services Office for Civil Rights.
• Statute of limitations on civil claims. FCRA private actions: the earlier of two years from discovery or five years from the violation (15 U.S.C. § 1681p). HRS § 480-13: four years (HRS § 480-24).
• Document retention. Keep originals of every notarized affidavit, certified-mail receipt, and CRA response indefinitely; ID-theft fallout often surfaces years later in mortgage applications or background checks.

9. SOURCES AND REFERENCES

• 15 U.S.C. § 1681c-2 (FCRA blocking) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 15 U.S.C. § 1681g(e) (Disclosure of records to victims) — https://www.law.cornell.edu/uscode/text/15/1681g
• 15 U.S.C. § 1681s-2 (Furnisher duties) — https://www.law.cornell.edu/uscode/text/15/1681s-2
• 12 C.F.R. § 1022.3(i) (Identity Theft Report) — https://www.ecfr.gov/current/title-12/chapter-X/part-1022/section-1022.3
• Haw. Rev. Stat. § 708-839.6 — https://www.capitol.hawaii.gov/hrscurrent/Vol14_Ch0701-0853/HRS0708/HRS_0708-0839_0006.htm
• Haw. Rev. Stat. § 708-839.7 — https://www.capitol.hawaii.gov/hrscurrent/Vol14_Ch0701-0853/HRS0708/HRS_0708-0839_0007.htm
• Haw. Rev. Stat. § 708-839.8 — https://www.capitol.hawaii.gov/hrscurrent/Vol14_Ch0701-0853/HRS0708/HRS_0708-0839_0008.htm
• Haw. Rev. Stat. ch. 487N (Security breach) — https://www.capitol.hawaii.gov/hrscurrent/Vol11_Ch0476-0490/HRS0487N/
• Haw. Rev. Stat. ch. 487J (SSN protection) — https://www.capitol.hawaii.gov/hrscurrent/Vol11_Ch0476-0490/HRS0487J/
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• DCCA Office of Consumer Protection — https://cca.hawaii.gov/ocp/
• Honolulu Police Department — https://www.honolulupd.org/
• Hawaii County Police Department — https://www.hawaiipolice.com/
• Maui Police Department — https://www.mauipolice.com/
• Kauai Police Department — https://www.kauai.gov/Government/Departments-Agencies/Police-Department

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Hawaii should review and customize this package before filing. Laws, citations, and procedures change frequently; verify all authorities before use.