Identity Theft Affidavit and Police Report Cover - Maryland

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — MARYLAND

TABLE OF CONTENTS

1. Part A — Maryland Police Report Cover Sheet
2. Part B — Sworn Identity Theft Affidavit
3. Part C — Creditor and CRA Dispute Cover Letter
4. Recovery Action Checklist
5. Maryland Practice Notes
6. Sources and References

1. PART A — MARYLAND POLICE REPORT COVER SHEET

TO: ☐ Maryland State Police, [BARRACK ADDRESS] ☐ [COUNTY / MUNICIPAL POLICE DEPARTMENT], [STATION ADDRESS]

Maryland State Police: https://mdsp.maryland.gov | Non-emergency: (410) 653-4200

Filing Locations (examples):

• Baltimore Police Department: https://www.baltimorepolice.org — (410) 396-2525
• Montgomery County Police: https://www.montgomerycountymd.gov/POL — (301) 279-8000
• Prince George's County Police: https://www.princegeorgescountymd.gov/police — (301) 352-1200
• Baltimore County Police: https://www.baltimorecountymd.gov/police — (410) 887-2222
• Anne Arundel County Police: https://www.aacounty.org/police — (410) 222-8050
• Howard County Police: https://www.howardcountymd.gov/police — (410) 313-2200

Statutory Basis for Report. This report is filed in connection with the criminal offense of Identity Fraud under Md. Code Ann., Crim. Law § 8-301 (and, if applicable, § 8-302 if a government-issued identifier was misused). The undersigned victim requests that this report be assigned a Case / Complaint Control Number and that a copy be provided to the victim for use in invoking the rights provided by the federal Fair Credit Reporting Act, 15 U.S.C. § 1681c-2 (block of information resulting from identity theft), 15 U.S.C. § 1681g(e) (right to obtain information from creditors), and the Maryland Personal Information Protection Act, Md. Code Ann., Com. Law § 14-3501 et seq.

Penalty Classification (Md. Code Ann., Crim. Law § 8-301(c)). ☐ Misdemeanor (benefit / value $100-$1,500: up to 12 months and $500 fine) ☐ Felony — value $1,500-$25,000 (up to 5 years and $10,000) ☐ Felony — value $25,000-$100,000 (up to 10 years and $15,000) ☐ Felony — value $100,000+ (up to 20 years and $25,000) ☐ Unknown at this time.

Brief Narrative. [Concise narrative: when discovered, how discovered, what accounts/identities were misused, suspected method (data breach, mail theft, lost wallet, phishing, family member, etc.).]

Restitution Request. Pursuant to Md. Code Ann., Crim. Law § 8-303 and Md. Code Ann., Crim. Proc. § 11-603, the victim hereby requests that any criminal disposition include restitution for actual losses incurred clearing credit records, reasonable attorney's fees, and other identity-theft recovery costs.

[________________________________]

[VICTIM SIGNATURE] Date: [__/__/____]

2. PART B — SWORN IDENTITY THEFT AFFIDAVIT

STATE OF MARYLAND

[COUNTY], ss.:

I, [VICTIM FULL LEGAL NAME], of [ADDRESS], [CITY], Maryland [ZIP], being first duly sworn, depose and state:

1. Identity. I am over the age of eighteen, of sound mind, and competent to make this affidavit. The facts stated herein are true and based on my personal knowledge.

2. Personal Identifying Information ("PII"). My PII as defined by Md. Code Ann., Crim. Law § 8-301(a) and Md. Code Ann., Com. Law § 14-3501(d) includes my name, date of birth, Social Security Number ending in [XXXX], [other identifiers — driver's license number, account numbers, biometric data, medical record numbers, passport number, taxpayer identification number], and the financial accounts identified below. I did not authorize any other person to use this PII for any purpose.

3. Date of Discovery. I first discovered the identity theft on or about [__/__/____] when [describe how discovered — credit report, denial of credit, collector contact, IRS notice, breach notification under Md. Code Ann., Com. Law § 14-3504, etc.].

4. Fraudulent Accounts and Activity. The following accounts, transactions, or applications were opened, attempted, or used WITHOUT my knowledge, permission, or authorization:

5. Non-Authorization. I did not open, authorize, ratify, benefit from, or receive any goods, services, or proceeds in connection with the accounts or activity identified in Paragraph 4. I have no business or personal relationship with the perpetrator(s) (or, if the perpetrator is known, see Paragraph 8).

6. Suspect. ☐ The perpetrator is unknown to me. ☐ I suspect or know that the perpetrator is [NAME / RELATIONSHIP], residing at [ADDRESS, if known]. Specifically, [describe basis].

7. Reports Filed. I have:

• ☐ Filed a report with the Federal Trade Commission at IdentityTheft.gov, FTC Identity Theft Report No. [________________________________], on [__/__/____].
• ☐ Filed a police report with [Maryland State Police / County Police / Municipal Police], Case / CCN [________________________________], on [__/__/____].
• ☐ Notified the Internal Revenue Service via Form 14039 (if tax-related). Date: [__/__/____].
• ☐ Notified the Social Security Administration (if SSN misuse). Date: [__/__/____].
• ☐ Notified the U.S. Postal Inspection Service (if mail theft suspected). Date: [__/__/____].
• ☐ Notified the Maryland Office of the Attorney General Identity Theft Unit at [email protected]. Date: [__/__/____].
• ☐ Notified each affected creditor or furnisher in writing.
• ☐ Placed an Initial Fraud Alert ☐ Extended Fraud Alert ☐ Security Freeze with each of Equifax, Experian, and TransUnion. Date(s): [__/__/____].

8. Cooperation. I am willing to assist law enforcement in the investigation and prosecution of any person or persons responsible for the identity theft, including providing testimony, exemplar signatures or biometrics, and additional documentation as requested.

9. FCRA Block Request. Pursuant to 15 U.S.C. § 1681c-2, I REQUEST that each consumer reporting agency BLOCK the reporting of all information identified in Paragraph 4 within four (4) business days after receipt of this affidavit and supporting documentation.

10. § 1681g(e) Request to Furnishers. Pursuant to 15 U.S.C. § 1681g(e), I REQUEST that each creditor and furnisher listed in Paragraph 4 provide me, free of charge and within thirty (30) days, copies of all application and business transaction records relating to the fraudulent accounts.

11. PIPA Demand (if applicable). If any defendant or its predecessor experienced a "breach of the security of a system" (Md. Code Ann., Com. Law § 14-3504(a)) implicating my PII, that entity owed me written notice within forty-five (45) days, and I demand that it produce its breach-investigation findings and notification records to me and to the Maryland Office of the Attorney General as required by § 14-3504(h).

12. Reservation of Civil Remedies. Nothing in this affidavit shall be construed as a waiver of any civil cause of action, including any claim under:

• Md. Code Ann., Crim. Law § 8-303 (criminal restitution);
• The Maryland Personal Information Protection Act, Md. Code Ann., Com. Law § 14-3501 et seq., and § 14-3508 (civil penalty / per se MCPA enforcement);
• The Maryland Consumer Protection Act, Md. Code Ann., Com. Law § 13-408 (private action with actual damages and attorney's fees), with PIPA and MCDCA violations being per se MCPA violations under § 13-301(14)(iii) and (xxix);
• The federal FCRA, 15 U.S.C. § 1681n (willful) and § 1681o (negligent);
• Common-law tort claims for negligence, breach of fiduciary duty, and invasion of privacy.

13. Truthfulness. I solemnly affirm under the penalties of perjury and upon personal knowledge that the contents of the foregoing document are true.

Executed on [__/__/____] at [CITY], Maryland.

[________________________________]

[VICTIM PRINTED NAME]

ACKNOWLEDGMENT

Sworn to and subscribed before me this [____] day of [_______________], 20[____], by [VICTIM NAME], who is personally known to me or produced [GOVERNMENT-ISSUED ID TYPE AND NUMBER] as identification.

[________________________________]

Notary Public, State of Maryland

(My Commission Expires: [_______________])

3. PART C — CREDITOR AND CRA DISPUTE COVER LETTER

[VICTIM NAME, ADDRESS, PHONE, EMAIL]

Date: [__/__/____]

VIA U.S. CERTIFIED MAIL — RETURN RECEIPT REQUESTED

Tracking No.: [________________________________]

[CREDITOR / CRA NAME]

Attn: Identity Theft / Fraud Department

[ADDRESS]

Re: Identity Theft Block and Investigation — Account/Reference No. [________________________________]

To Whom It May Concern:

I am a victim of identity theft. The account or item identified above was not opened or authorized by me. Enclosed for your reference and processing are:

• ☐ Exhibit 1 — FTC Identity Theft Report (No. [________________________________]) from IdentityTheft.gov
• ☐ Exhibit 2 — Maryland Police Report (Case / CCN [________________________________])
• ☐ Exhibit 3 — Sworn Maryland Identity Theft Affidavit (notarized)
• ☐ Exhibit 4 — Copy of government-issued photo ID
• ☐ Exhibit 5 — Proof of address (utility bill or lease)

Pursuant to 15 U.S.C. § 1681c-2 (CRAs) and 15 U.S.C. § 1681s-2 (furnishers), I demand that you:

1. Block / cease reporting the fraudulent account or item from my consumer file within four (4) business days (CRAs).
2. Cease all collection activity on the fraudulent account.
3. Provide me, free of charge, copies of all applications and business records relating to the fraudulent account (15 U.S.C. § 1681g(e)) within thirty (30) days.
4. Notify any third party to whom you have furnished information about the fraudulent account that the account is the result of identity theft.
5. Confirm in writing that the account has been blocked/closed/removed and is being reported as such.

I expressly reserve all civil remedies, including without limitation those under the FCRA (15 U.S.C. § 1681n, § 1681o), the Maryland Identity Fraud restitution provisions (Md. Code Ann., Crim. Law § 8-303), the Maryland Personal Information Protection Act (Md. Code Ann., Com. Law § 14-3501 et seq., § 14-3508), and the Maryland Consumer Protection Act (Md. Code Ann., Com. Law § 13-408 — actual damages and reasonable attorney's fees).

Sincerely,

[________________________________]

[VICTIM NAME]

4. RECOVERY ACTION CHECKLIST

• ☐ Pull free credit reports from Equifax, Experian, and TransUnion at AnnualCreditReport.com.
• ☐ File FTC report at IdentityTheft.gov; print recovery plan and Identity Theft Report.
• ☐ File police report with the Maryland State Police or local police covering the jurisdiction where the theft occurred or where the victim resides; obtain Case / CCN.
• ☐ Notarize this Affidavit.
• ☐ Place Fraud Alert (Initial 1-yr or Extended 7-yr) — only one CRA need be contacted; it will notify the others.
• ☐ Place Security Freeze with all three CRAs (free under Md. Code Ann., Com. Law § 14-1212.1).
• ☐ Send Affidavit + reports + ID + proof of address by Certified Mail to each affected creditor/furnisher and to each CRA.
• ☐ Send IRS Form 14039 if tax-related.
• ☐ Notify Social Security Administration if SSN misused.
• ☐ Notify the Maryland Office of the Attorney General Identity Theft Unit ([email protected]; (410) 576-6491).
• ☐ Change all account passwords; enable two-factor authentication.
• ☐ Review medical records (medical identity theft) and request corrections under HIPAA.
• ☐ Calendar 30-day follow-up for FCRA reinvestigation results (15 U.S.C. § 1681i).
• ☐ Preserve every collector communication, account statement, breach notice, and notice for evidence.
• ☐ Consider consulting an attorney about civil recovery under PIPA and the MCPA, especially if a data-breach defendant or negligent furnisher is identifiable.

5. MARYLAND PRACTICE NOTES

• Maryland Identity Fraud (Crim. Law § 8-301). Knowingly, willfully, and with fraudulent intent obtaining or possessing another's PII to obtain a benefit, or assuming another's identity to evade prosecution, obtain a benefit, access health care, or avoid a financial obligation. Tier penalties scale with the value obtained: misdemeanor (under $1,500) up through felony (20 years and $25,000 fine for $100,000+).
• Government identity fraud (§ 8-302). Misuse of a government-issued identifying document (driver's license, passport, Social Security card, etc.) carries enhanced penalties.
• Restitution. Md. Code Ann., Crim. Law § 8-303 expressly authorizes restitution to the victim for losses incurred restoring credit and reputation, in addition to direct out-of-pocket loss. Submit a written restitution request before sentencing.
• Maryland Personal Information Protection Act (PIPA). Md. Code Ann., Com. Law § 14-3501 et seq. requires a business holding "personal information" to (i) implement reasonable security procedures (§ 14-3503), (ii) investigate any suspected breach in good faith and promptly (§ 14-3504), (iii) notify the Maryland Attorney General as soon as practicable but not later than 10 days before consumer notice (§ 14-3504(h)), and (iv) notify affected Maryland residents within 45 days. Notice content is prescribed by statute.
• PIPA private remedy. A violation of PIPA is "an unfair, abusive, or deceptive trade practice" within the meaning of the MCPA and is enforceable both by the Attorney General and by private action. Md. Code Ann., Com. Law § 14-3508. The MCPA private right of action under § 13-408 carries actual damages plus reasonable attorney's fees.
• Free freezes. Maryland residents are entitled to free placement, lifting, and removal of security freezes under Md. Code Ann., Com. Law § 14-1212.1. No fee may be charged.
• FTC Report = sworn affidavit substitute. Under 15 U.S.C. § 1681a(q)(4), an FTC Identity Theft Report functions as the sworn affidavit for blocking. Most CRAs additionally require a police report; Maryland CRAs and furnishers will accept State Police or local-jurisdiction reports.
• Police-report jurisdiction. File with the Maryland law-enforcement agency for the jurisdiction where the victim resides. If the theft occurred in another county or state, file there as well. The Maryland State Police will accept reports for residents of unincorporated areas not served by a county or municipal department.
• Attorney General Identity Theft Unit. The Maryland OAG operates a dedicated Identity Theft Unit at the Consumer Protection Division. Contact: (410) 576-6491; [email protected]; 200 St. Paul Place, 16th Floor, Baltimore, MD 21202.
• Statute of limitations on civil claims. PIPA, MCPA, and MCDCA actions are subject to the general three-year limitations period of Md. Code Ann., Cts. & Jud. Proc. § 5-101.
• Children. Special procedures apply under FCRA § 1681c-2A for victims under 16. Freeze the child's file. Maryland recognizes minor freezes at no cost.
• Mail theft. If mail was stolen, file a complaint with the U.S. Postal Inspection Service (uspis.gov).
• Tax identity theft. File IRS Form 14039 and notify the Comptroller of Maryland (marylandtaxes.gov) for state-tax identity theft.

6. SOURCES AND REFERENCES

• Md. Code Ann., Crim. Law § 8-301 (Identity fraud) — https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gcr&section=8-301
• Md. Code Ann., Crim. Law § 8-302 (Government identity fraud) — https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gcr&section=8-302
• Md. Code Ann., Crim. Law § 8-303 (Restitution; victim certification) — https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gcr&section=8-303
• Md. Code Ann., Com. Law § 14-3501 (PIPA Definitions) — https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gcl&section=14-3501
• Md. Code Ann., Com. Law § 14-3504 (Breach notification) — https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gcl&section=14-3504
• Md. Code Ann., Com. Law § 14-3508 (PIPA enforcement / MCPA) — https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gcl&section=14-3508
• Md. Code Ann., Com. Law § 14-1212.1 (No-fee freeze) — https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gcl&section=14-1212.1
• 15 U.S.C. § 1681c-2 (FCRA blocking) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• Maryland State Police — https://mdsp.maryland.gov
• Maryland Office of the Attorney General Identity Theft Unit — https://www.marylandattorneygeneral.gov/Pages/IdentityTheft/default.aspx
• AnnualCreditReport.com — https://www.annualcreditreport.com/
• IRS Form 14039 — https://www.irs.gov/forms-pubs/about-form-14039
• Comptroller of Maryland — https://www.marylandtaxes.gov/
• U.S. Postal Inspection Service — https://www.uspis.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Consult a qualified Maryland attorney for advice on your specific identity theft circumstances and any potential civil recovery.