Identity Theft Affidavit and Police Report Cover Letter - Massachusetts

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER LETTER — MASSACHUSETTS

Massachusetts identity theft remedies layer four legal frameworks: (1) the federal Fair Credit Reporting Act (15 U.S.C. § 1681c-1 / § 1681c-2) governing fraud alerts and tradeline blocking; (2) the Massachusetts criminal identity-fraud statute (M.G.L. c. 266 § 37E); (3) Massachusetts data-breach and information-security law (M.G.L. c. 93H and 201 CMR 17.00) requiring breach notifications and data safeguards; and (4) the Massachusetts free security freeze right under M.G.L. c. 93H § 3A. Use of any of these frameworks may be supplemented by a Chapter 93A consumer claim where a covered entity fails to act on a properly served identity theft package.

TABLE OF CONTENTS

• PART A: FTC Identity Theft Report Instructions
• PART B: Identity Theft Affidavit
• PART C: Police Report Cover Letter (Massachusetts)
• PART D: Massachusetts-Specific Identity Theft Protections
• PART E: Supporting Documentation Checklist
• PART F: Recipient List
• Sources and References

PART A: FTC IDENTITY THEFT REPORT INSTRUCTIONS

Step 1: File an FTC Identity Theft Report

The Federal Trade Commission provides a centralized identity theft reporting system at IdentityTheft.gov. The FTC report is the document used to invoke FCRA § 1681c-2 tradeline blocking and § 1681c-1 extended (7-year) fraud alerts.

Procedure:

1. Visit https://www.identitytheft.gov
2. Create an account (recommended) or proceed without one
3. Answer the questions about the identity theft incident
4. Receive an Identity Theft Report and personalized recovery plan
5. Print and save the Identity Theft Report — copies are needed for creditors, CRAs, and law enforcement

Step 2: Contact the Three Major Credit Reporting Agencies

Step 3: Place Fraud Alerts (Federal — Free, Nationwide)

• Initial Fraud Alert (1 Year): contact ONE CRA; that agency must notify the other two.
• Extended Fraud Alert (7 Years): available to confirmed identity theft victims with an FTC Identity Theft Report; removes consumer from prescreened credit-offer lists for five (5) years.

Step 4: Place Security Freezes — Massachusetts Free-Freeze Right

Massachusetts law grants every consumer the right to place, temporarily lift, or permanently remove a security freeze at no cost under M.G.L. c. 93H § 3A and (for a CRA) 209 CMR 18.04. Federal law (15 U.S.C. § 1681c-1) also makes freezes free nationwide.

Massachusetts Freeze Mechanics:

• A CRA must place the freeze within 3 business days of receiving a written request (and within 24 hours upon proper electronic request under federal law).
• Lift requests must be honored within 3 business days of mailed request or within 15 minutes of an authenticated electronic request.
• A freeze blocks new-credit issuers from pulling the consumer's credit file without consumer-initiated lift.

Step 5: Massachusetts Data-Breach Notification Tracking

If the identity theft stemmed from a data breach, the breaching entity is REQUIRED under M.G.L. c. 93H § 3 to notify (a) you, (b) the Office of Consumer Affairs and Business Regulation (OCABR), and (c) the Office of the Attorney General. Where the breach involved a Social Security number, the entity must offer at least 18 months of free credit monitoring (or 42 months if the breached entity is a CRA).

Confirm whether you received a breach notice; if you did not but suspect a breach occurred, file a complaint with OCABR (https://www.mass.gov/orgs/office-of-consumer-affairs-and-business-regulation) and the AG.

PART B: IDENTITY THEFT AFFIDAVIT

SECTION 1: VICTIM INFORMATION

Full Legal Name: [________________________________]

Former / Maiden / Other Names Used: [________________________________]

Date of Birth: [__/__/____]

Social Security Number: [____] - [____] - [____]

Current Massachusetts Address:

Street: [________________________________]

City: [________________________________] State: MA ZIP: [____]

How long at this address? [________________________________]

Previous Address (if at current address less than 2 years):

Street: [________________________________]

City: [________________________________] State: [____] ZIP: [____]

Home Phone: [________________________________]

Work Phone: [________________________________]

Cell Phone: [________________________________]

Email Address: [________________________________]

Massachusetts Driver's License or RMV ID Number: [________________________________]

SECTION 2: FRAUDULENT ACCOUNT INFORMATION

Complete one entry for each fraudulent account. Attach additional pages if necessary.

Fraudulent Account #1

Fraudulent Account #2

Fraudulent Account #3

(Attach additional pages using the same format for additional fraudulent accounts.)

SECTION 3: HOW THE IDENTITY THEFT OCCURRED

How did you first discover the identity theft?

[________________________________]
[________________________________]
[________________________________]

When did the identity theft first occur (best estimate)? [__/__/____]

When did you first discover the identity theft? [__/__/____]

Do you know or suspect how the identity thief obtained your personal information?

☐ Lost or stolen wallet / purse
☐ Lost or stolen mail
☐ Data breach notification received (Company: [________________________________])
☐ Stolen from home, car, or office
☐ Someone I know had access to my information
☐ Phishing email or phone scam
☐ Online data compromise
☐ Medical or insurance records theft
☐ Tax-related identity theft
☐ Massachusetts RMV / state agency breach
☐ Unknown
☐ Other: [________________________________]

SECTION 4: KNOWN OR SUSPECTED PERPETRATOR INFORMATION

Do you know or suspect who committed the identity theft?

☐ No — Skip to Section 5
☐ Yes — Complete below

Suspected Perpetrator's Name: [________________________________]

Relationship to Victim: [________________________________]

Last Known Address: [________________________________]

Phone Number: [________________________________]

Other Identifying Information: [________________________________]

Why do you suspect this person?

[________________________________]
[________________________________]

SECTION 5: TIMELINE OF EVENTS AND ACTIONS TAKEN

SECTION 6: ACTIONS ALREADY TAKEN

☐ Filed FTC Identity Theft Report at IdentityTheft.gov — Report Number: [________________________________]
☐ Filed police report — Agency: [________________________________] Report Number: [________________________________]
☐ Placed initial fraud alert (1-year) with: ☐ Equifax ☐ Experian ☐ TransUnion — Date: [__/__/____]
☐ Placed extended fraud alert (7-year) — Date: [__/__/____]
☐ Placed Massachusetts security freeze with: ☐ Equifax ☐ Experian ☐ TransUnion — Date: [__/__/____]
☐ Requested free credit reports from all three CRAs
☐ Contacted affected creditors / financial institutions
☐ Contacted debt collectors regarding fraudulent debts
☐ Filed complaint with Massachusetts AG Consumer Advocacy & Response Division
☐ Filed complaint with Office of Consumer Affairs and Business Regulation (OCABR)
☐ Filed complaint with Massachusetts Division of Banks (financial institution complaints)
☐ Filed IRS Identity Theft Affidavit (Form 14039) — if tax-related
☐ Notified the Massachusetts Department of Revenue (state tax fraud)
☐ Contacted the Social Security Administration — if SSN compromised
☐ Contacted U.S. Postal Inspection Service — if mail theft involved
☐ Notified Massachusetts RMV — if driver's license number was compromised
☐ Changed passwords and PINs on all accounts
☐ Other: [________________________________]

SECTION 7: DECLARATION UNDER PAINS AND PENALTIES OF PERJURY

I, [________________________________], declare under the pains and penalties of perjury under the laws of the Commonwealth of Massachusetts and the United States that the information provided in this affidavit is true and correct to the best of my knowledge. I understand that knowingly making false statements may subject me to criminal prosecution under M.G.L. c. 268, § 1A (perjury) and 18 U.S.C. § 1001 (false statements to federal agencies).

I did not authorize any person to use my personal identifying information to open or access any of the accounts or to conduct any of the transactions listed in this affidavit. I am willing to cooperate fully with any law enforcement agency, creditor, or consumer reporting agency investigating this identity theft.

Signature: ________________________________________

Printed Name: [________________________________]

Date: [__/__/____]

NOTARIZATION BLOCK

COMMONWEALTH OF MASSACHUSETTS

COUNTY OF [________________________________], ss.

On this [____] day of [_______________], 20[____], before me, the undersigned notary public, personally appeared [________________________________], proved to me through satisfactory evidence of identification, which was [☐ Massachusetts driver's license ☐ Massachusetts ID ☐ Passport ☐ Other:_____], to be the person whose name is signed on this document and acknowledged to me that he/she signed it voluntarily for its stated purpose.

Notary Public Signature: ________________________________________

Printed Name: [________________________________]

My Commission Expires: [__/__/____]

Notary Seal:

[SEAL]

Note: Massachusetts notaries are commissioned by the Governor. The Commonwealth requires the notary to record satisfactory evidence of identification under Executive Order 455 (04-04) and 950 CMR 17.00.

PART C: POLICE REPORT COVER LETTER (MASSACHUSETTS)

[__/__/____]

[Police Department Name]

[Street Address]

[City, MA ZIP]

Re: Request to File Identity Theft Police Report — M.G.L. c. 266 § 37E

Dear Officer / Detective:

I am writing to request that your department accept and file an identity theft report. I am a victim of identity fraud and need an official Massachusetts police report to exercise my rights under the federal Fair Credit Reporting Act (15 U.S.C. § 1681 et seq.) and to support my claims under Massachusetts consumer-protection law (M.G.L. c. 93A).

Background

My personal identifying information has been used without my authorization to open fraudulent accounts, make unauthorized transactions, and/or commit other fraudulent acts as detailed in the attached Identity Theft Affidavit. The total known fraudulent activity amounts to approximately $[________________________________].

Massachusetts Criminal Law — M.G.L. c. 266 § 37E

Massachusetts criminalizes identity fraud under M.G.L. c. 266 § 37E with the following framework:

"Personal Identifying Information" Defined

Under M.G.L. c. 266 § 37E(a), "personal identifying information" includes any name or number that may be used, alone or in conjunction with other information, to assume the identity of an individual, including: name, address, telephone number, driver's license number, Social Security number, place of employment, employee identification number, mother's maiden name, demand deposit account number, savings account number, credit card number, and computer password identification.

Information and Documents I Am Providing

☐ Completed Identity Theft Affidavit (attached)
☐ FTC Identity Theft Report (attached)
☐ Government-issued photo identification
☐ Proof of current Massachusetts address
☐ Credit reports showing fraudulent accounts (highlighted)
☐ Collection notices for fraudulent debts
☐ Correspondence from creditors
☐ Documentation of financial losses
☐ Other supporting evidence: [________________________________]

Request

I respectfully request that you:

1. Accept this identity theft report and assign a case number;
2. Provide me with a certified copy of the filed police report;
3. Investigate the identity theft to the extent possible;
4. Refer the matter to the appropriate investigative unit (local detective bureau, district attorney's office, Massachusetts State Police Cyber Crime Unit, or U.S. Secret Service Electronic Crimes Task Force as appropriate).

Massachusetts AG guidance directs all Massachusetts police departments to accept identity theft reports from victims regardless of where the offense occurred. See https://www.mass.gov/info-details/massachusetts-law-about-identity-theft.

Respectfully,

Signature: ________________________________________

Printed Name: [________________________________]

Address: [________________________________]

Phone: [________________________________]

Email: [________________________________]

PART D: MASSACHUSETTS-SPECIFIC IDENTITY THEFT PROTECTIONS

Massachusetts Data Breach Notification Law — M.G.L. c. 93H

The Massachusetts Data Breach Notification Law applies to any person or entity that owns or licenses personal information about a Massachusetts resident:

• Trigger: "Breach of security" — unauthorized acquisition or use of unencrypted personal information (or encrypted data plus the key) creating a substantial risk of identity theft or fraud.
• Personal information defined (§ 1): First name (or initial) + last name + any of: SSN, driver's license / state ID number, financial-account number, or credit-card number (with PIN/access code where required).
• Recipients of notice (§ 3): (a) the affected resident; (b) the Massachusetts Attorney General; (c) the Office of Consumer Affairs and Business Regulation (OCABR).
• Timing: "As soon as practicable and without unreasonable delay" upon knowledge of breach.
• Content of notice: Right to obtain a police report, how to request a security freeze, fees (none in MA), and contact information for the major CRAs.
• Credit monitoring: If SSN was breached, the entity must provide 18 months free credit monitoring (42 months if the breaching entity is a CRA). M.G.L. c. 93H § 3A.
• Civil penalties: Up to $5,000 per violation under M.G.L. c. 93A § 4 enforcement, plus AG injunctive authority.

Massachusetts Standards for Personal-Information Protection — 201 CMR 17.00

201 CMR 17.00 (Standards for the Protection of Personal Information of Residents of the Commonwealth) requires every person who owns or licenses Massachusetts-resident personal information to develop and maintain a Written Information Security Program (WISP) including:

• Designation of one or more responsible employees;
• Risk assessment;
• Reasonable physical, administrative, and technical safeguards;
• Encryption of personal information stored on portable devices and transmitted across public networks;
• Vendor oversight and regular WISP review.

Failure to maintain a 201 CMR 17.00–compliant WISP supplies an independent unfair / deceptive act under M.G.L. c. 93A § 2.

Massachusetts Free Security Freeze — M.G.L. c. 93H § 3A

• Consumer right to place, lift, or remove a credit freeze at no cost on each of the three nationwide CRAs.
• CRA must place the freeze within 3 business days of mailed request and within 24 hours of authenticated electronic request (federal § 1681c-1).
• CRA must lift the freeze within 3 business days of mailed request or 15 minutes of an authenticated electronic request (federal).

Massachusetts AG Consumer Advocacy & Response Division

Office of Consumer Affairs and Business Regulation (OCABR)

Massachusetts Division of Banks

For complaints involving financial institutions, mortgage servicers, or licensed debt collectors:

PART E: SUPPORTING DOCUMENTATION CHECKLIST

Required Documents

☐ Completed Identity Theft Affidavit (Part B above)
☐ FTC Identity Theft Report from IdentityTheft.gov
☐ Massachusetts police report with case number
☐ Government-issued photo identification (Massachusetts driver's license, Mass. ID, or passport)
☐ Proof of current Massachusetts address (utility bill, lease, bank statement)

Massachusetts-Specific Documents

☐ M.G.L. c. 93H breach notification letter (if identity theft resulted from a data breach)
☐ OCABR breach-notification confirmation (if applicable)
☐ Massachusetts AG complaint confirmation (if filed)
☐ Massachusetts RMV report (if driver's license / state ID was compromised)

Credit-Related Documents

☐ Credit reports from all three CRAs with fraudulent items highlighted
☐ Fraud alert confirmation letters
☐ Security freeze confirmation letters / PINs
☐ Credit monitoring alerts

Fraudulent Account Documents

☐ Statements or notices for fraudulent accounts
☐ Collection letters for fraudulent debts
☐ Correspondence with creditors regarding disputes
☐ Denial letters for credit applications you did not make

Financial Impact Documents

☐ Bank statements showing unauthorized transactions
☐ Records of out-of-pocket expenses
☐ Records of lost wages or time spent resolving identity theft
☐ Documentation of denied credit, employment, or housing

Communication Records

☐ Log of all phone calls (date, time, person spoken to, reference numbers)
☐ Copies of all letters sent (with certified mail receipts)
☐ Email correspondence with creditors, CRAs, and law enforcement

PART F: RECIPIENT LIST — WHO TO SEND THE AFFIDAVIT TO

Use certified mail with return receipt requested for all mailings.

1. Credit Reporting Agencies (All Three)

2. Each Affected Creditor or Financial Institution

3. Debt Collectors Pursuing Fraudulent Accounts

4. Massachusetts Attorney General — Consumer Advocacy & Response Division

One Ashburton Place, 18th Floor, Boston, MA 02108

5. Office of Consumer Affairs and Business Regulation (OCABR)

501 Boylston Street, Suite 5100, Boston, MA 02116

6. Massachusetts Division of Banks (financial institution complaints)

1000 Washington Street, 10th Floor, Boston, MA 02118

7. Internal Revenue Service (If Tax-Related)

IRS Identity Protection Specialized Unit: 1-800-908-4490

8. Massachusetts Department of Revenue (state tax-related)

P.O. Box 7010, Boston, MA 02204 — (617) 887-MDOR

9. Social Security Administration (If SSN Compromised)

Phone: 1-800-772-1213 | Report fraud: oig.ssa.gov

10. Massachusetts RMV (if driver's license or state ID compromised)

https://www.mass.gov/orgs/massachusetts-registry-of-motor-vehicles

SOURCES AND REFERENCES

• Federal Trade Commission — IdentityTheft.gov: https://www.identitytheft.gov
• Fair Credit Reporting Act, 15 U.S.C. § 1681 et seq.: https://www.law.cornell.edu/uscode/text/15/chapter-41/subchapter-III
• M.G.L. c. 266 § 37E (Identity Fraud): https://malegislature.gov/Laws/GeneralLaws/PartIV/TitleI/Chapter266/Section37E
• M.G.L. c. 93H (Data Breach Notification): https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXV/Chapter93h
• M.G.L. c. 93H § 3A (Free Security Freeze)
• 201 CMR 17.00 (Standards for the Protection of Personal Information): https://www.mass.gov/regulations/201-CMR-1700-standards-for-the-protection-of-personal-information-of-residents-of-the-commonwealth
• Massachusetts Law about Identity Theft (AG guidance): https://www.mass.gov/info-details/massachusetts-law-about-identity-theft
• Mass. AG Consumer Hotline: https://www.mass.gov/info-details/consumer-services-at-the-attorney-generals-office
• Office of Consumer Affairs and Business Regulation (Data Breach Reporting): https://www.mass.gov/info-details/data-breach-reporting
• Massachusetts Division of Banks: https://www.mass.gov/orgs/division-of-banks
• Annual Free Credit Reports: https://www.annualcreditreport.com
• IRS Identity Theft Information: https://www.irs.gov/identity-theft-fraud-scams

This template is provided for informational purposes only and does not constitute legal advice. Massachusetts identity theft remedies cross multiple federal and state agencies; consult a Massachusetts-licensed attorney for advice specific to your situation.