Identity-Theft Report and Recovery Request Pack — Illinois

ILLINOIS IDENTITY-THEFT REPORT AND RECOVERY REQUEST PACK

1. SAFETY, SCOPE, AND DATA-MINIMIZATION GATE

A. Urgent route

☐ There is an immediate risk of physical harm, active account takeover, funds leaving an account, arrest, eviction, utility shutoff, loss of medical care, or a filing deadline. Immediate action taken: [911 / BANK FRAUD LINE / COURT COUNSEL / OTHER].

☐ Criminal charges, warrants, arrest records, or convictions appear under the victim's identity. Counsel or an official criminal-identity route was contacted on [DATE].

☐ Tax, Social Security, unemployment, public-benefit, immigration, driver's-license, medical, child-support, or business-identity misuse is involved. Correct agency-specific route: [AGENCY / FORM / DEADLINE].

B. Sensitive-data rules

☐ Full Social Security number, full date of birth, account credentials, PINs, and unredacted identity documents are omitted unless the specific recipient requires them through a verified secure channel.

☐ Account numbers are limited to the last four digits in general correspondence.

☐ Each recipient's current address, portal, upload limits, identity-proof rules, and permitted delivery methods were verified directly on [DATE].

☐ Copies—not irreplaceable originals—will be sent unless the recipient expressly requires an original.

☐ Delivery proof and an exact copy of each submission will be retained.

2. INCIDENT AND EVIDENCE INTAKE

Consumer name: [FULL LEGAL NAME]

Preferred secure contact: [PHONE / EMAIL / MAILING ADDRESS]

Date first discovered: [DATE]

How discovered: [FACTS]

Date personal information was lost, stolen, exposed, or first misused, if known: [DATE / UNKNOWN]

A. Misuse inventory

B. Known or suspected perpetrator

☐ Unknown.

☐ Known or suspected: [NAME / RELATIONSHIP].

Facts supporting—not merely assuming—the suspicion: [FACTS]

Potential safety concern from identifying the person: [YES / NO / DETAILS]

C. Authorization statement

For each item retained in the final statement:

☐ I did not open, authorize, sign, use, or benefit from the identified account or transaction.

☐ The statement above needs qualification: [AUTHORIZED PORTION / SHARED ACCOUNT / PRIOR RELATIONSHIP / BENEFIT / OTHER FACT].

3. MODULE A — ILLINOIS POLICE-REPORT COVER

[CONSUMER NAME]

[MAILING ADDRESS]

[SAFE PHONE / EMAIL]

Date: [DATE]

[LOCAL LAW-ENFORCEMENT AGENCY WITH JURISDICTION OVER ACTUAL RESIDENCE]

[CURRENT ADDRESS OR VERIFIED SUBMISSION ROUTE]

Re: Request under 720 ILCS 5/16-35(a) concerning suspected unlawful use of personal identifying information

To the receiving officer or unit:

I have learned or reasonably suspect that another person unlawfully used my personal identifying information. I reside at [ACTUAL RESIDENCE, OR PROVIDE SECURELY AS DIRECTED], within this agency's jurisdiction.

The suspected misuse is described in the attached incident statement and evidence index. In summary, [BRIEF FACTS: WHO DID WHAT, WHEN, AND HOW DISCOVERED].

Under 720 ILCS 5/16-35(a), I request that the agency:

1. take a police report of the matter;
2. provide me a copy of the report; and
3. begin investigating the facts or, if the suspected crime occurred elsewhere, refer the matter to the law-enforcement agency where it occurred.

Please record the report number, receiving officer or employee, date, and any referral information below or provide them with the report copy.

I understand that I must provide accurate information and that the agency controls its intake, interview, evidence, and referral procedures. I am available at [SAFE CONTACT].

Sincerely,

Signature: [SIGNATURE]

Name: [NAME]

Police intake record

4. MODULE B — FACTUAL IDENTITY-THEFT STATEMENT

A. Statement

I, [FULL LEGAL NAME], state:

1. I learned or reasonably suspect that my identifying information was used without my authority as described below.
2. I discovered the suspected misuse on [DATE] through [SOURCE].
3. The exact information or identity element used, stated only to the level safe and necessary here, was [TYPE OF IDENTIFIER].
4. The unauthorized acts are the numbered items [NUMBERS] in the misuse inventory attached as Exhibit [A].
5. For each identified item, I did not [OPEN / AUTHORIZE / SIGN / USE / BENEFIT FROM] it, subject to this exact qualification: [NONE / FACTS].
6. Known dates, account identifiers, furnishers, documents, and suspected-perpetrator information appear in the attached evidence index.
7. Additional facts that may assist an investigation or validate a recovery request are [FACTS].

I declare that the factual statements above are true and correct to the best of my knowledge. I understand that knowingly providing false information to law enforcement, a consumer reporting agency, or another recipient may carry legal consequences.

Date: [DATE]

Signature: [SIGNATURE]

Printed name: [NAME]

B. Recipient-specific execution gate

☐ Recipient accepts a signed statement without notarization.

☐ Recipient reasonably requested a notarized affidavit or its own form. Requirement and source: [DETAILS].

Optional notary block—use only if required or advised

Subscribed and sworn before me on [DATE] by [NAME].

Notary signature: [SIGNATURE]

Commission expires: [DATE]

5. MODULE C — CONSUMER-REPORT BLOCK REQUEST

[CONSUMER NAME AND SAFE RETURN ADDRESS]

Date: [DATE]

[CONSUMER REPORTING AGENCY]

[CURRENT VERIFIED BLOCK-REQUEST ADDRESS OR PORTAL]

Re: Identity-theft block request under 15 U.S.C. § 1681c-2

I request a block of the reporting of each item identified in the attached schedule because it resulted from alleged identity theft and does not relate to any transaction by me.

This submission includes:

☐ appropriate proof of my identity in the form and secure channel the agency currently requires;

☐ a copy of my identity theft report;

☐ a schedule identifying each item to be blocked, including the furnisher, safe account identifier, and exact disputed reporting; and

☐ my signed statement that each listed item is not information relating to a transaction by me, with any necessary qualification stated precisely.

Please process this request under Section 1681c-2, send the notices the section requires, and provide the result through [SAFE CONTACT METHOD].

Signature: [SIGNATURE]

Name: [NAME]

Block schedule

6. MODULE D — BUSINESS-RECORD REQUEST

[CONSUMER NAME AND SAFE RETURN ADDRESS]

Date: [DATE]

[BUSINESS ENTITY]

[ADDRESS THE BUSINESS SPECIFIES FOR § 1681g(e) REQUESTS, IF ANY]

Re: Written request for identity-theft application and transaction records under 15 U.S.C. § 1681g(e)

I request, without charge, copies of application and business-transaction records in your control that evidence the alleged identity-theft transaction identified below:

Please provide the records to:

☐ me at [SECURE DELIVERY ROUTE];

☐ the following law-enforcement agency or officer specified by me: [NAME / ADDRESS / REPORT NUMBER]; and/or

☐ the investigating agency authorized by me to receive them: [NAME / AUTHORIZATION].

I include the identity and claim verification selected or reasonably requested under Section 1681g(e)(2): [LIST]. I also include the relevant transaction information readily obtainable by me.

Please respond within the period and under the procedures stated in Section 1681g(e). If you decline or cannot locate records, identify the statutory ground or explain the search and availability issue in writing.

Signature: [SIGNATURE]

Name: [NAME]

7. MODULE E — THIRD-PARTY DEBT-COLLECTOR NOTICE

[CONSUMER NAME AND SAFE RETURN ADDRESS]

Date: [DATE]

[DEBT COLLECTOR]

[CURRENT VERIFIED DISPUTE OR CORRESPONDENCE ADDRESS]

Re: Notice that debt information may be fraudulent or identity-theft-related; 15 U.S.C. § 1681m(g)

I notify you that information relating to the debt below may be fraudulent or may result from identity theft:

Collector reference: [SAFE ID]

Claimed creditor: [NAME]

Claimed amount: $[AMOUNT]

Reason challenged: [FACTS]

Under Section 1681m(g), please notify the creditor or other third party on whose behalf you are collecting that the information may be fraudulent or identity-theft-related.

I also request all information I otherwise would be entitled to receive if I were disputing the debt under law applicable to you. Please identify the current creditor, the claimed basis and amount, and the route for obtaining available dispute information.

Attached are [IDENTITY THEFT REPORT / POLICE REPORT / SUPPORTING RECORDS / IDENTITY PROOF ONLY IF REQUIRED AND SECURE].

Signature: [SIGNATURE]

Name: [NAME]

8. FRAUD-ALERT, FREEZE, AND ACCOUNT-CONTROL CHECKLIST

☐ Initial fraud alert requested from a nationwide CRA on [DATE]; identity proof and confirmation: [DETAILS].

☐ Extended fraud alert requested with an identity theft report on [DATE]; confirmation: [DETAILS].

☐ Security freeze placed separately with each relevant consumer reporting agency using its current official process; PIN, password, or recovery code stored securely.

☐ Existing financial, email, telephone, shopping, payment, benefits, tax, and device accounts secured using unique credentials and multifactor authentication where available.

☐ Financial institutions notified through verified fraud channels; cards, checks, transfers, payment tokens, and account access reviewed.

☐ Credit reports and specialty reports reviewed for exact fraudulent items and inquiries.

9. EVIDENCE AND DELIVERY INDEX

10. RESPONSE AND DEADLINE LOG

11. CURRENT OFFICIAL HELP ROUTES

• Federal Trade Commission reporting and recovery plan: https://www.identitytheft.gov/
• Illinois Attorney General identity-theft resources and current complaint materials: https://illinoisattorneygeneral.gov/consumer-protection/identity-theft/
• Illinois Attorney General Identity Theft Hotline, verified 2026-08-22: 1-866-999-5630; hearing or speech disabilities: 7-1-1 relay service.

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A qualified Illinois attorney should review it when legal rights, deadlines, litigation, criminal records, or significant loss are involved.