Identity Theft Affidavit and Police Report Cover — Kentucky

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — KENTUCKY

TABLE OF CONTENTS

1. Affiant Information
2. Statement Under Oath
3. Description of Identity Theft
4. Fraudulent Accounts and Charges
5. FCRA § 605B Block Request
6. Consumer Reporting Agency Cover Letter
7. Police Report Cover Sheet
8. Notarization
9. Kentucky Practice Notes
10. Sources and References

1. AFFIANT INFORMATION

2. STATEMENT UNDER OATH

COMMONWEALTH OF KENTUCKY

COUNTY OF [COUNTY]

I, [CONSUMER NAME], being duly sworn, depose and state as follows:

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 am the victim of identity theft as defined by 15 U.S.C. § 1681a(q)(3) and KRS § 514.160.

2.3. I did not authorize, consent to, or benefit from any of the accounts, charges, applications, or transactions identified in Section 4 below. I did not commit, conspire in, or facilitate any of the acts described.

2.4. I have not received and did not retain any goods, services, money, or other benefit from any of the disputed transactions.

2.5. I am providing this affidavit to law enforcement, consumer reporting agencies, furnishers, and other entities for the purpose of (a) blocking fraudulent information from my consumer reports under 15 U.S.C. § 1681c-2, (b) obtaining records under 15 U.S.C. § 1681g(e), (c) initiating a criminal investigation under KRS § 514.160, and (d) preserving my rights under federal and Kentucky law.

2.6. I understand that providing false information in this affidavit may subject me to criminal prosecution under federal law and under KRS Chapter 523 (Perjury and Related Offenses).

3. DESCRIPTION OF IDENTITY THEFT

3.1. I first discovered the identity theft on or about [__/__/____] when [describe how discovered — e.g., received a collection letter, denied credit, reviewed credit report, received data-breach letter under KRS § 365.732].

3.2. To the best of my knowledge, the personal information used by the thief was obtained as follows: [describe — e.g., physical theft of wallet, mail theft, phishing email, data breach at NAMED COMPANY, lost laptop, household member, unknown].

3.3. [If applicable] I received a data-breach notification dated [__/__/____] from [ENTITY] describing a breach of personally identifiable information under KRS § 365.732. A copy is attached as Exhibit A.

3.4. [If applicable] I have a reasonable basis to believe the perpetrator is [NAME / RELATIONSHIP / "unknown"]. [Provide any identifying information — known address, phone, vehicle, IP address, email used, screenshots, photos.]

3.5. I have closed and / or disputed each fraudulent account identified in Section 4.

3.6. I have placed the following protections on my credit file:

☐ Initial fraud alert (90-day) — placed with [Equifax / Experian / TransUnion] on [__/__/____].

☐ Extended fraud alert (7-year) — placed with all three CRAs on [__/__/____].

☐ Credit freeze / security freeze — placed with all three CRAs on [__/__/____].

4. FRAUDULENT ACCOUNTS AND CHARGES

I declare under penalty of perjury that none of the accounts or charges listed above were opened, made, or authorized by me.

5. FCRA § 605B BLOCK REQUEST

Pursuant to 15 U.S.C. § 1681c-2 (FCRA § 605B), I request that each consumer reporting agency receiving this affidavit BLOCK the fraudulent information identified in Section 4 from my consumer file within four (4) business days of receipt. In support of this request, I am providing:

☐ Proof of identity (copy of Kentucky driver's license / ID and a utility bill or bank statement, with full SSN redacted except last four digits);

☐ A copy of an identity-theft report (this affidavit and the attached Kentucky police / sheriff incident report and / or FTC IdentityTheft.gov report);

☐ Identification of the information to be blocked (Section 4 above; supporting tradeline screenshots attached as Exhibit B);

☐ My statement that the information is not the result of any transaction by me (Section 4 closing declaration above).

I further request, pursuant to 15 U.S.C. § 1681s-2(a)(6), that the CRA notify each furnisher of the disputed information of my identity-theft claim and direct each furnisher to cease furnishing the information.

6. CONSUMER REPORTING AGENCY COVER LETTER

Date: [__/__/____]

SENT VIA U.S. CERTIFIED MAIL — RETURN RECEIPT REQUESTED

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

Experian, P.O. Box 9701, Allen, TX 75013

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

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

Consumer: [CONSUMER NAME]

DOB: [__/__/____] | Last 4 SSN: [____]

Current Address: [STREET, CITY, KY ZIP]

To Whom It May Concern:

I am a victim of identity theft. Pursuant to 15 U.S.C. § 1681c-2 (FCRA § 605B), I request that you (a) BLOCK the fraudulent tradelines identified in the enclosed affidavit, (b) notify each furnisher under 15 U.S.C. § 1681s-2(a)(6), (c) place an extended fraud alert under 15 U.S.C. § 1681c-1(b), and (d) provide me a free copy of my consumer report under 15 U.S.C. § 1681j(d).

Enclosed are:

☐ Sworn identity-theft affidavit (this document);

☐ Kentucky law-enforcement incident report dated [__/__/____], agency [________], case no. [________];

☐ FTC IdentityTheft.gov report no. [________];

☐ Proof of identity (driver's license / utility bill);

☐ Annotated tradeline printouts identifying the fraudulent items.

Please confirm in writing within four (4) business days that you have placed the requested block.

Sincerely,

[________________________________]

[CONSUMER NAME]

7. POLICE REPORT COVER SHEET

Date: [__/__/____]

[KENTUCKY LAW ENFORCEMENT AGENCY NAME]

[STREET ADDRESS]

[CITY, KY ZIP]

Re: Request to Take Identity-Theft Report — KRS § 514.160

Reporting Party: [CONSUMER NAME] | DOB [__/__/____]

Address: [STREET, CITY, KY ZIP] | Phone [________]

Officer / Detective: [________________________________] Badge [________]

Dear Officer:

I am the victim of identity theft and am requesting that your agency take a formal incident report. Identity theft is a Class D felony under KRS § 514.160. Under 15 U.S.C. § 1681a(q)(4), a report filed with a law-enforcement agency qualifies as an "identity theft report" and is required to obtain a permanent block of fraudulent information from my consumer credit file.

Attached, please find:

☐ Sworn and notarized identity-theft affidavit (this document);

☐ FTC IdentityTheft.gov report no. [________] dated [__/__/____];

☐ Schedule of fraudulent accounts and charges (Section 4 above);

☐ Supporting documentation: [breach notice / collection letters / credit-report excerpts / screenshots].

Please provide me with a copy of the incident report and the case number for use with the consumer reporting agencies and furnishers. Pursuant to 15 U.S.C. § 1681g(e) and FTC guidance, I may need to share the report with creditors so they can produce transaction records to law enforcement and to me.

Thank you for your assistance.

Sincerely,

[________________________________]

[CONSUMER NAME]

8. NOTARIZATION

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

[________________________________]

Notary Public, Commonwealth of Kentucky

(My Commission Expires: [_______________])

(Notary Seal)

9. KENTUCKY PRACTICE NOTES

• Kentucky theft of identity. KRS § 514.160 makes it a Class D felony to knowingly possess or use another's identifying information with intent to represent that one is the other person, including for financial or credit transactions, avoiding detection, or commercial benefit. Kentucky law enforcement has jurisdiction in the county of the victim's residence or where the offense occurred.
• Kentucky data breach. KRS § 365.732 requires "information holders" doing business in Kentucky to notify Kentucky residents of breaches involving unencrypted personally identifiable information that has caused or is reasonably believed to have caused identity theft or fraud. Breach notices may identify the source of the theft and should be preserved.
• Kentucky Consumer Data Protection Act. Effective January 1, 2026, KRS Chapter 367 (Subchapters governing the KCDPA) adds new consumer rights and complaint procedures handled by the Kentucky AG's Office of Data Privacy. Consider parallel filing if the theft involves a covered controller.
• FCRA blocking timeline. Under 15 U.S.C. § 1681c-2, the CRA must block within four (4) business days of receiving the four required items. Furnishers receive notice and must cease furnishing under § 1681s-2(a)(6).
• Permanent block versus temporary fraud alert. Initial fraud alerts last 90 days. Extended fraud alerts (with an identity-theft report) last 7 years. § 605B blocks are intended to be permanent unless the CRA properly rescinds them under § 1681c-2(c).
• Transaction records. Use 15 U.S.C. § 1681g(e) to demand the furnisher produce application and transaction records within 30 days. The FTC sample 609(e) letter is on IdentityTheft.gov.
• Tax-related identity theft. File IRS Form 14039 (federal) and notify the Kentucky Department of Revenue if KY tax accounts are affected. Kentucky DOR maintains a separate ID-theft hotline.
• Preserve everything. Keep originals of breach notices, collection letters, certified-mail green cards, CRA confirmation letters, and law-enforcement case numbers. They are evidence in any subsequent FCRA, FDCPA, or KCPA litigation.
• KCPA overlay. A KCPA claim against a furnisher or breached entity is viable only where Plaintiff purchased or leased goods or services from that defendant or its privy. See Skilcraft Sheetmetal, Inc. v. Kentucky Mach., Inc., 836 S.W.2d 907 (Ky. Ct. App. 1992).

10. SOURCES AND REFERENCES

• 15 U.S.C. § 1681c-2 (FCRA § 605B) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 15 U.S.C. § 1681a(q) (definitions) — https://www.law.cornell.edu/uscode/text/15/1681a
• 15 U.S.C. § 1681g(e) (transaction records) — https://www.law.cornell.edu/uscode/text/15/1681g
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• KRS § 514.160 (Theft of identity) — https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=19818
• KRS § 365.732 (Data breach notification) — https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=43326
• Kentucky AG Identity Theft Resources — https://www.ag.ky.gov/Resources/Consumer-Resources/Pages/default.aspx
• Kentucky State Police — https://kentuckystatepolice.org/
• IRS Identity Theft Affidavit (Form 14039) — https://www.irs.gov/forms-pubs/about-form-14039
• Equifax Identity Theft Help — https://www.equifax.com/personal/identity-theft-protection/
• Experian Fraud Center — https://www.experian.com/fraud/center.html
• TransUnion Fraud Victim Resources — https://www.transunion.com/fraud-victim-resource/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Kentucky should review and customize this document before signing or sending. Filing a false affidavit or police report is itself a crime. Verify all citations and procedures before use.