Identity Theft Affidavit and Police Report Cover (Louisiana)

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — LOUISIANA

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 Louisiana Law Enforcement Agency
6. Notarization and Verification
7. Distribution List
8. Louisiana Practice Notes
9. Sources and References

1. AFFIANT INFORMATION

2. SWORN STATEMENT OF IDENTITY THEFT

STATE OF LOUISIANA

PARISH 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, I am of the full age of majority, and I am 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 as criminalized by La. R.S. § 14:67.16.

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, breach notice received under La. R.S. § 51:3074].

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 — e.g., [PARISH] Sheriff's Office or [MUNICIPALITY] Police Department] 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. I make this Affidavit for the purposes of (i) obtaining a police report from a Louisiana law enforcement agency; (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, restitution, or sentencing proceeding under La. R.S. § 14:67.16 and the Louisiana Code of Criminal Procedure; and (vi) supporting any civil claim under the Louisiana Unfair Trade Practices and Consumer Protection Law (La. R.S. § 51:1401 et seq.) or the Louisiana Database Security Breach Notification Law (La. R.S. § 51:3071 et seq.).

2.10. 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 (Louisiana driver's license, Louisiana Special ID, or U.S. passport).

☐ Exhibit 3. Proof of Louisiana 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. Any La. R.S. § 51:3074 breach-notification letter received from a Louisiana entity holding the affiant's personal information.

☐ Exhibit 9. Other: [describe].

5. COVER LETTER TO LOUISIANA LAW ENFORCEMENT AGENCY

[DATE]

[LAW ENFORCEMENT AGENCY NAME — Sheriff's Office / Police Department]

Attn: Records Division / Financial Crimes / Identity Theft Unit

[STREET ADDRESS]

[CITY, LA ZIP]

RE: Request to File a Police Report — Identity Theft Victim — La. R.S. § 14:67.16

Dear Officer / Records Division:

I am a Louisiana resident and the victim of identity theft as defined by La. R.S. § 14:67.16. I respectfully request that your agency open an incident or investigative report concerning the identity theft described herein.

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 Louisiana address (Exhibit 3);
• Supporting documentation of fraudulent activity (Exhibit 4);
• Copies of my consumer credit reports with disputed items marked (Exhibit 5);
• Any La. R.S. § 51:3074 data-breach notification I have received (Exhibit 8).

I respectfully request:

1. That your agency open an incident or case report and provide me with a report number and a certified copy of the report when available;

2. That investigative referrals be made to the appropriate Louisiana State Police Cyber Crime Unit, Louisiana Bureau of Investigation, U.S. Postal Inspection Service, U.S. Secret Service, FBI, or other agency as warranted;

3. That a copy of the report be flagged for any subsequent restitution proceeding under La. C. Cr. P. art. 883.2 or any felony sentencing under La. R.S. § 14:67.16 (which authorizes fines and imprisonment scaling with the amount of loss).

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 duly commissioned for the State of Louisiana, this [____] day of [_______________], 20[____].

[________________________________]

Notary Public

State of Louisiana, Parish of [______________]

Notary / Bar Roll No.: [______]

(My Commission is for life or expires: [_______________])

(Notary Seal)

7. DISTRIBUTION LIST

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

8. LOUISIANA PRACTICE NOTES

• Right to a police report. Louisiana does not impose a single statutory mandate (analogous to some states) requiring police to take an identity-theft report at the victim's residence. As a practical matter, parish sheriff's offices and municipal police departments in Louisiana will accept identity-theft reports from residents. If an officer declines, ask for a supervisor, cite La. R.S. § 14:67.16, and request that the matter be referred to the financial-crimes or cyber-crimes detective.
• Elements of Louisiana identity theft. Under La. R.S. § 14:67.16(B), identity theft is the intentional use, possession, transfer, or attempted use, with fraudulent intent, of any personal identifying information of another person to obtain, possess, or transfer credit, money, goods, services, or anything else of value without authorization.
• Sentencing tiers. La. R.S. § 14:67.16(C) imposes felony penalties scaling with the amount obtained: $1,000 or more — up to 10 years and/or up to $10,000; $500–$999 and $300–$499 — up to 3 years and/or up to $3,000. Enhanced minimums apply when the victim is age 60 or older, a person with a disability, or a minor under 17.
• Restitution. La. C. Cr. P. art. 883.2 authorizes restitution to the victim. Document time spent (logs, hourly value), out-of-pocket costs (postage, certified mail, document fees), and any professional fees incurred. Submit a victim impact statement to the prosecutor.
• 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.
• Louisiana Database Security Breach Notification Law. La. R.S. § 51:3071 et seq. requires any person or entity conducting business in Louisiana that owns or licenses computerized data including personal information to notify Louisiana residents within 60 days of breach discovery (La. R.S. § 51:3074). Notice to the AG is required within 10 days of consumer notice. If the affiant's information has been compromised in a breach, request a copy of the breach letter, AG notice, and remedial offerings (credit monitoring, freeze fees waived).
• Security freeze. Louisiana law (La. R.S. § 9:3568.1 et seq.) 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.
• LUTPA leverage. A breach or merchant pattern that contributed to the identity theft may give rise to a LUTPA claim under La. R.S. § 51:1401 et seq. Treble damages on knowing violations after AG notice and attorney's fees are available under § 51:1409. Note one-year prescription.
• IRS identity theft. If the affiant suspects fraudulent tax filings using their SSN, file IRS Form 14039 and request an Identity Protection PIN.
• 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.
• Solidary liability. Multiple actors that concur in causing identity-theft harm — e.g., a careless data custodian and a fraudulent merchant — may be liable in solido (La. C.C. art. 2324).

9. SOURCES AND REFERENCES

• La. R.S. § 14:67.16 (Identity theft) — https://legis.la.gov/Legis/Law.aspx?d=78613
• La. R.S. § 51:3071 et seq. (Database Security Breach Notification Law) — https://legis.la.gov/Legis/Law.aspx?d=322027
• La. R.S. § 51:3074 (Notification timing; AG notice) — https://www.legis.la.gov/legis/Law.aspx?d=322030
• La. R.S. § 9:3568.1 et seq. (Louisiana security-freeze law)
• La. C. Cr. P. art. 883.2 (Restitution to victims)
• La. R.S. § 51:1401 et seq. (LUTPA) — https://legis.la.gov/legis/Law.aspx?d=104033
• 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/
• Louisiana Attorney General — Consumer Protection — https://www.ag.louisiana.gov/Page/ConsumerDispute/
• Louisiana State Police — https://www.lsp.org

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