Identity Theft Affidavit and Police Report Cover (Indiana)

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — INDIANA

TABLE OF CONTENTS

1. Affiant Information
2. Sworn Statement of Identity Theft
3. Schedule A — Fraudulent Accounts and Transactions
4. Schedule B — Documents Attached
5. Cover Letter to Law Enforcement Agency
6. Notarization and Verification
7. Distribution List
8. Indiana Practice Notes
9. Sources and References

1. AFFIANT INFORMATION

2. SWORN STATEMENT OF IDENTITY THEFT

STATE OF INDIANA

COUNTY OF [______________]

I, [AFFIANT NAME], after being first duly sworn, depose and state under oath as follows:

2.1. I am the natural person identified in Section 1 above, and I am over the age of 18 and competent to make this Affidavit.

2.2. I am the victim of identity theft as that term is defined by 15 U.S.C. § 1681a(q)(3) and Ind. Code § 35-40-14-1, and as criminalized in Indiana by Ind. Code § 35-43-5-3.5 (identity deception).

2.3. I first became aware of the identity theft on or about [__/__/____] by virtue of [describe — e.g., notice from creditor, denial of credit, debt collection call, suspicious activity on credit report, IRS notice, data-breach notification under Ind. Code § 24-4.9-3-1].

2.4. I did not authorize, consent to, ratify, or benefit from the use of my identifying information in the accounts or transactions identified in Schedule A below.

2.5. I have not and do not give permission to any person to use my name, Social Security number, date of birth, address, driver's license number, or other identifying information to apply for, open, use, or transact business on any account identified in Schedule A.

2.6. To the best of my knowledge and belief, I do not personally know the perpetrator(s) of the identity theft. [OR: To the best of my knowledge and belief, the person(s) responsible for the identity theft is/are: (name(s) and relationship)].

2.7. I have filed or am simultaneously filing this Affidavit with [LAW ENFORCEMENT AGENCY NAME] to obtain a police report concerning the identity theft.

2.8. I have submitted, or am simultaneously submitting, an identity theft report to the Federal Trade Commission via IdentityTheft.gov, and a copy of the FTC affidavit is attached as Exhibit 1.

2.9. [If applicable] The identity theft is connected to a known data security breach disclosed under Ind. Code § 24-4.9-3-1 by [ENTITY NAME] on or about [__/__/____]. A copy of the breach notification is attached as Exhibit __.

2.10. I make this Affidavit for the purposes of (i) obtaining a police report; (ii) constituting an "Identity Theft Report" under 15 U.S.C. § 1681a(q)(4) for use with consumer reporting agencies and creditors; (iii) supporting requests under 15 U.S.C. § 1681c-2 to block reporting of fraudulent information; (iv) supporting requests under 15 U.S.C. § 1681g(e) for disclosure of records concerning fraudulent accounts; (v) supporting any criminal investigation, prosecution, or restitution proceeding under Ind. Code § 35-43-5-3.5 and § 35-50-5-3 (restitution); and (vi) supporting any civil enforcement action by the Indiana Attorney General under the Indiana Disclosure of Security Breach Act, Ind. Code § 24-4.9.

2.11. The statements made in this Affidavit, including those in Schedule A, are true and correct based on my personal knowledge except where stated upon information and belief, and as to those matters I believe them to be true.

[________________________________]

[AFFIANT NAME], Affiant

3. SCHEDULE A — FRAUDULENT ACCOUNTS AND TRANSACTIONS

4. SCHEDULE B — DOCUMENTS ATTACHED

☐ Exhibit 1. FTC IdentityTheft.gov-generated affidavit (printed at completion; cannot be retrieved later).

☐ Exhibit 2. Copy of government-issued photo ID (driver's license, passport, or state ID).

☐ Exhibit 3. Proof of address (recent utility bill, bank statement, lease, or property tax bill — within last 60 days).

☐ Exhibit 4. Copies of fraudulent account notices, billing statements, or collection letters.

☐ Exhibit 5. Copies of credit reports from Equifax, Experian, and TransUnion with fraudulent items circled.

☐ Exhibit 6. Police report cover letter (Section 5 below) and any prior incident reports.

☐ Exhibit 7. Fraud alert / security freeze confirmations from each of the three nationwide CRAs.

☐ Exhibit 8. Indiana data-breach notification under Ind. Code § 24-4.9-3-1 (if any).

☐ Exhibit 9. Other: [describe].

5. COVER LETTER TO LAW ENFORCEMENT AGENCY

[DATE]

[LAW ENFORCEMENT AGENCY NAME]

Attn: Records Division / Identity Theft Unit

[STREET ADDRESS]

[CITY, IN ZIP]

RE: Request to File a Police Report — Identity Theft Victim — Ind. Code § 35-43-5-3.5

Dear Officer / Records Division:

I am an Indiana resident and the victim of identity deception as defined by Ind. Code § 35-43-5-3.5 and as that term is defined for victim purposes by Ind. Code § 35-40-14-1. I respectfully request that your agency, which has jurisdiction over my residence, accept and process this report even where some or all of the underlying conduct may have occurred elsewhere.

Attached for your records are:

• This Identity Theft Affidavit (Sections 1 through 6) sworn under oath;
• A schedule of fraudulent accounts and transactions (Schedule A);
• A copy of the FTC IdentityTheft.gov affidavit (Exhibit 1);
• A copy of my government-issued photo ID (Exhibit 2);
• Proof of my Indiana address (Exhibit 3);
• Supporting documentation of fraudulent activity (Exhibit 4);
• Copies of my consumer credit reports with disputed items marked (Exhibit 5);
• [If applicable] Indiana data-breach notification (Exhibit 8).

I respectfully request:

1. That your agency open an incident or case report and provide me a report number and a certified copy of the report when available;
2. That investigative referrals be made to the appropriate Indiana State Police, Indiana Attorney General Identity Theft Unit, U.S. Postal Inspection Service, U.S. Secret Service, or other agency as warranted;
3. That a copy of the report be flagged for any subsequent restitution proceeding under Ind. Code § 35-50-5-3.

I understand that the police report, together with the FTC affidavit, will constitute an "Identity Theft Report" under 15 U.S.C. § 1681a(q)(4), which I will then submit to the consumer reporting agencies and creditors to invoke the blocking and dispute rights afforded by 15 U.S.C. § 1681c-2 and 15 U.S.C. § 1681g(e).

Thank you for your assistance.

Sincerely,

[________________________________]

[AFFIANT NAME]

[CONTACT TELEPHONE / EMAIL]

6. NOTARIZATION AND VERIFICATION

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

[________________________________]

Notary Public

State of Indiana, County of [______________]

My commission expires: [__/__/____]

(Notary Seal)

7. DISTRIBUTION LIST

After execution and (if applicable) issuance of a police report, distribute as follows:

8. INDIANA PRACTICE NOTES

• Indiana identity deception statute. Ind. Code § 35-43-5-3.5 defines identity deception as knowingly or intentionally obtaining, possessing, transferring, or using identifying information of another with intent to harm or defraud — a Level 6 felony, elevated to a Level 5 felony where the offender uses information of more than 100 persons, where the fair market value of the harm is at least $50,000, or where the victim is under 18. It is not a defense that no person was actually harmed or defrauded.
• Right to file a report. Indiana law does not contain a single express residence-jurisdiction filing-right statute analogous to Georgia's O.C.G.A. § 16-9-129, but agencies routinely accept identity-theft reports at the victim's residence. The Indiana Attorney General Consumer Protection Division operates an Identity Theft Unit that accepts and refers complaints; in practice, file with both local police and the Indiana AG.
• Restitution. Indiana courts may order restitution to identity-theft victims under Ind. Code § 35-50-5-3 as part of any criminal sentence. Document time spent (logs, hourly value), out-of-pocket costs (postage, certified mail, document fees), and any professional fees incurred.
• Indiana Disclosure of Security Breach Act overlay. Ind. Code § 24-4.9 requires database owners to disclose breaches of personal information to affected Indiana residents without unreasonable delay and not more than 45 days after discovery. Database owners must also notify the Indiana Attorney General. If the affiant's theft traces to a breach, the AG enforcement track (with civil penalties up to $150,000 per deceptive act under Ind. Code § 24-4.9-4-1 / IDCSA cross-reference) is available — and the breach notification itself is powerful evidence.
• Identity Theft Report under FCRA. The FTC affidavit ALONE is not an "Identity Theft Report" sufficient to compel a § 605B block. It must be paired with a police report (or, in some circumstances, a report to a federal, state, or local law enforcement agency). 16 C.F.R. § 603.3.
• § 605B block timing. A consumer reporting agency must block disputed information within four (4) business days of receiving (i) appropriate proof of identity, (ii) a copy of the Identity Theft Report, and (iii) a statement that the information is not the result of any transaction by the consumer, plus identification of the information to be blocked. 15 U.S.C. § 1681c-2(a).
• § 1681g(e) records request. Within 30 days of receiving a sufficient request from a victim, a creditor or financial institution must furnish business records (application, transaction history, etc.) related to the alleged fraudulent account. The victim can use these records to support both civil and criminal proceedings.
• Security freeze in Indiana. Ind. Code § 24-5-24 (and federal law, 15 U.S.C. § 1681c-1) authorize free security freezes for any consumer. Place freezes with all three nationwide CRAs to prevent new-account fraud while disputes are pending.
• IRS identity theft. If the affiant suspects fraudulent tax filings using their SSN, file IRS Form 14039 and request an Identity Protection PIN.
• Indiana BMV. If a driver's license or BMV record is implicated, file a separate fraud report with the Indiana Bureau of Motor Vehicles.
• Avoid revealing full SSN beyond necessary recipients. Use only the last four digits in copies furnished to creditors or third parties; provide full SSN only to law enforcement and credit reporting agencies as required.

9. SOURCES AND REFERENCES

• Ind. Code § 35-43-5-3.5 (Identity deception) — https://iga.in.gov/laws/2024/ic/titles/35/#35-43-5-3.5
• Ind. Code § 35-40-14-1 ("Identity theft" definition) — https://law.justia.com/codes/indiana/title-35/article-40/chapter-14/section-35-40-14-1/
• Ind. Code § 35-50-5-3 (Restitution) — https://iga.in.gov/laws/2024/ic/titles/35/#35-50-5-3
• Ind. Code § 24-4.9 (Disclosure of Security Breach) — https://iga.in.gov/laws/2024/ic/titles/24/#24-4.9
• Ind. Code § 24-4.9-3-1 (Disclosure of breach) — https://law.justia.com/codes/indiana/title-24/article-4-9/chapter-3/section-24-4-9-3-1/
• Ind. Code § 24-5-24 (Security freezes) — https://iga.in.gov/laws/2024/ic/titles/24/#24-5-24
• 15 U.S.C. § 1681a(q) — https://www.law.cornell.edu/uscode/text/15/1681a
• 15 U.S.C. § 1681c-1 (Fraud alerts) — https://www.law.cornell.edu/uscode/text/15/1681c-1
• 15 U.S.C. § 1681c-2 (Block of information resulting from identity theft) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 15 U.S.C. § 1681g(e) (Records disclosure to victim) — https://www.law.cornell.edu/uscode/text/15/1681g
• 16 C.F.R. § 603.3 (FTC definition of "identity theft report")
• IdentityTheft.gov — https://www.identitytheft.gov/
• Indiana Attorney General — Identity Theft Prevention — https://www.in.gov/attorneygeneral/consumer-protection-division/id-theft-prevention/
• Indiana AG Security Breach Notification (business resources) — https://www.in.gov/attorneygeneral/consumer-protection-division/id-theft-prevention/security-breaches/
• Indiana State Police — https://www.in.gov/isp/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Indiana must review and customize this document before use. Laws, citations, and court rules change frequently; verify all authorities before use.