Identity Theft Affidavit and Police Report Cover - Maine

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — MAINE

TABLE OF CONTENTS

1. Police Report Cover Letter
2. Identity Theft Affidavit
3. Schedule A — Fraudulent Accounts and Transactions
4. FCRA § 1681c-2 Block Request — to Each Nationwide CRA
5. Notarization
6. Maine Practice Notes
7. Sources and References

1. POLICE REPORT COVER LETTER

[VICTIM FULL LEGAL NAME]

[STREET ADDRESS]

[CITY, ME ZIP]

Telephone: [________________]

Email: [________________]

Date: [__/__/____]

[POLICE DEPARTMENT NAME]

Attn: Records / Identity Theft Unit

[STREET ADDRESS]

[CITY, ME ZIP]

Re: Request to File Identity Theft Police Report Under 17-A M.R.S. § 905-A

Dear Officer in Charge:

I am a resident of [CITY, COUNTY], Maine, and I am a victim of identity theft. I am submitting this request and the attached sworn Identity Theft Affidavit to file a police report under 17-A M.R.S. § 905-A (Misuse of Identification). Maine law entitles me to a written police report of this matter, and I respectfully request:

1. That a police report be opened and a case number issued;
2. That a copy of the report be provided to me at the address above for use with consumer reporting agencies, creditors, and the Maine Attorney General's Consumer Protection Division;
3. That the report identify, where known, each fraudulent account, transaction, or use of my identifying information; and
4. That, if the alleged perpetrator is known to me, I be informed of the steps that will be taken.

I have also filed a report with the Federal Trade Commission at IdentityTheft.gov. The FTC report number is [________________________________].

Enclosed are: (a) my sworn Identity Theft Affidavit; (b) Schedule A listing fraudulent accounts; (c) a copy of my government-issued photo ID; (d) proof of address; and (e) supporting documents.

Sincerely,

[________________________________]

[VICTIM NAME]

Enclosures: Affidavit; Schedule A; Photo ID; Proof of address; Supporting documents

2. IDENTITY THEFT AFFIDAVIT

STATE OF MAINE

COUNTY OF [________________], ss.

I, [VICTIM FULL LEGAL NAME], being first duly sworn, depose and state as follows:

A. Identity of Affiant

A.1. My full legal name is [________________________________].

A.2. My date of birth is [__/__/____].

A.3. The last four digits of my Social Security number are [XXX-XX-____].

A.4. My current residential address is [STREET, CITY, ME ZIP].

A.5. My residential addresses for the past five (5) years are: [________________________________].

A.6. My driver's license or state-ID number is [________________] issued by [STATE].

B. Statement of Identity Theft

B.1. I am a victim of identity theft as defined by 16 C.F.R. § 603.3 and 17-A M.R.S. § 905-A. A person or persons unknown to me (or known to me as identified in Paragraph B.5 below) has used or attempted to use my personal identifying information without my permission to obtain credit, money, goods, services, or other things of value.

B.2. I first discovered the identity theft on or about [__/__/____] when [DESCRIBE DISCOVERY EVENT — e.g., received collection letter; reviewed credit report; was denied credit; received bill for unknown account].

B.3. I did not authorize, consent to, ratify, or benefit from any of the fraudulent accounts, charges, applications, or transactions listed in Schedule A.

B.4. I did not receive any goods, services, money, credit, or other thing of value as a result of the fraudulent accounts and transactions.

B.5. [CHOOSE ONE]

☐ I do NOT know who committed the identity theft.

☐ I DO know or suspect the following person(s) committed the identity theft: [NAME, RELATIONSHIP, ADDRESS].

B.6. I did not authorize anyone to use my identifying information to apply for credit or obtain goods or services. No spouse, partner, parent, child, or other family member has authority to use my identity for any of the accounts or transactions identified in Schedule A.

B.7. The identity theft is associated with [CHOOSE ALL THAT APPLY]:

☐ Stolen wallet, purse, or mail dated [__/__/____].

☐ Lost or stolen Social Security card, driver's license, or other ID.

☐ Data breach involving [NAME OF ENTITY] notified under 10 M.R.S. § 1346 et seq. on or about [__/__/____].

☐ Phishing, vishing, or smishing communication received on or about [__/__/____].

☐ Computer or device compromise.

☐ Other: [________________________________].

C. Steps Taken

C.1. I have placed an [INITIAL FRAUD ALERT / EXTENDED FRAUD ALERT / SECURITY FREEZE] with each of the three nationwide consumer reporting agencies pursuant to 15 U.S.C. § 1681c-1 and 10 M.R.S. § 1350-B on [__/__/____].

C.2. I have filed an FTC Identity Theft Report at IdentityTheft.gov, FTC Report No. [________________________________].

C.3. I have filed a police report with [POLICE DEPARTMENT], Case No. [________________________________], on [__/__/____].

C.4. I have notified each creditor and financial institution listed in Schedule A by certified mail and have requested in writing that the fraudulent accounts be closed and removed from my credit file.

C.5. I have not been arrested or charged with any crime arising from the misuse of my identity. (If I have been, the circumstances are: [________________________________].)

D. Acknowledgments

D.1. I acknowledge that knowingly making a false statement on this affidavit may be punishable as unsworn falsification (17-A M.R.S. § 453) or perjury (17-A M.R.S. § 451).

D.2. I authorize the recipient of this affidavit to use it solely for the purpose of investigating, blocking, or correcting fraudulent accounts and transactions and to share it with law enforcement and consumer reporting agencies for the same purpose.

D.3. I request that all credit bureaus, creditors, and businesses receiving this affidavit:

• Block fraudulent information under 15 U.S.C. § 1681c-2;
• Provide me with copies of all account-opening documents, applications, statements, and transaction records pursuant to 15 U.S.C. § 1681g(e);
• Cease all collection of, and reporting on, the fraudulent accounts.

3. SCHEDULE A — FRAUDULENT ACCOUNTS AND TRANSACTIONS

Total Disputed Amount: $[________________]

4. FCRA § 1681c-2 BLOCK REQUEST

The undersigned hereby requests, pursuant to 15 U.S.C. § 1681c-2, that the consumer reporting agency receiving this affidavit BLOCK all information identified in Schedule A from appearing in any consumer report furnished about the undersigned. Required attachments are enclosed:

1. Proof of identity: copy of government-issued photo ID and Social Security card or substitute proof under 16 C.F.R. § 1022.123;
2. Identity theft report: police report (Section 1) and/or FTC IdentityTheft.gov report;
3. Schedule A specifically identifying the information to be blocked; and
4. Sworn statement that the information is not the result of any transaction by the undersigned (Affidavit Paragraphs B.3–B.6 above).

The undersigned further requests, pursuant to 15 U.S.C. § 1681g(e), that all furnishers of the blocked information provide copies of any application, account-opening documents, and transaction records related to the fraudulent accounts.

Send to each of the following nationwide CRAs:

• Equifax Information Services LLC, P.O. Box 105069, Atlanta, GA 30348 — https://www.equifax.com/personal/credit-report-services/identity-theft-protection/
• Experian, P.O. Box 9554, Allen, TX 75013 — https://www.experian.com/fraud/center.html
• TransUnion LLC, Fraud Victim Assistance Department, P.O. Box 2000, Chester, PA 19016 — https://www.transunion.com/fraud-victim-resource/

5. NOTARIZATION

Signed under the pains and penalties of perjury this [____] day of [_______________], 20[____].

[________________________________]

[VICTIM NAME] — Affiant

STATE OF MAINE

COUNTY OF [_______________], ss.

Subscribed and sworn to before me this [____] day of [_______________], 20[____], by [VICTIM NAME], who is personally known to me or who produced [FORM OF ID] as identification.

[________________________________]

Notary Public / Attorney-at-Law

Print Name: [________________________________]

(Commission Expires: [__/__/____])

[NOTARY SEAL]

6. MAINE PRACTICE NOTES

• Right to a police report. Maine law entitles victims of misuse of identification under 17-A M.R.S. § 905-A to file and obtain a written police report. If a department refuses, escalate to the Maine State Police or the Maine Attorney General's office. A police report is essential to obtain an FCRA § 1681c-2 block.
• FTC IdentityTheft.gov report. An FTC Identity Theft Report (generated at IdentityTheft.gov) qualifies as an "identity theft report" for FCRA purposes (16 C.F.R. § 603.3). File both the FTC report AND a Maine police report — many creditors require both.
• Security freeze (free for victims). Under 10 M.R.S. § 1350-B and 15 U.S.C. § 1681c-1, identity-theft victims may place a security freeze with each CRA at no charge. Obtain freeze PINs and store securely.
• Data-breach overlay. If your information was compromised in a breach, the breached entity is required by 10 M.R.S. §§ 1347–1348 to notify you. Demand a copy of the breach notice and any free credit-monitoring offer. The Maine AG enforces under 10 M.R.S. § 1349 with civil penalties up to $500 per violation (capped at $2,500 per day).
• Tax-related identity theft. File IRS Form 14039 (Identity Theft Affidavit) and Maine Revenue Services Form 1040ME-IDT for state-level tax theft. Also place an IRS Identity Protection PIN.
• Medical identity theft. Send an additional dispute and request for accounting under HIPAA (45 C.F.R. § 164.528) to each medical provider.
• Criminal identity theft. If charges have been filed against you in someone else's name, work with the prosecutor and court to obtain a "clearance letter" or expungement and affidavit of factual innocence.
• Civil remedies. Where the theft was facilitated by a creditor's failure to follow reasonable account-opening procedures, consider FCRA § 1681s-2 furnisher claims and a Maine UTPA claim under 5 M.R.S. § 207.
• Continuing duty to monitor. Identity theft often manifests in waves over 12–36 months. Pull all three credit reports quarterly via AnnualCreditReport.com and re-dispute new fraud as it appears.

7. SOURCES AND REFERENCES

• 17-A M.R.S. § 905-A — https://legislature.maine.gov/legis/statutes/17-A/title17-Asec905-A.html
• 10 M.R.S. § 1346 et seq. (Notice of Risk to Personal Data Act) — https://legislature.maine.gov/legis/statutes/10/title10ch210-Bsec0.html
• 10 M.R.S. § 1350-B (Security freeze) — https://legislature.maine.gov/statutes/10/title10sec1350-B.html
• 15 U.S.C. § 1681c-2 (FCRA block) — https://www.consumerfinance.gov/rules-policy/regulations/1022/
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• FTC Identity Theft Affidavit — https://www.identitytheft.gov/Assistant
• Maine AG Consumer Protection — https://www.maine.gov/ag/consumer/
• Maine State Police — https://www.maine.gov/dps/msp/
• IRS Form 14039 — https://www.irs.gov/forms-pubs/about-form-14039

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