Identity Theft Affidavit and Police Report Cover (Minnesota)

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER (MINNESOTA)

TABLE OF CONTENTS

1. Identity Theft Affidavit — Caption and Oath
2. Victim Identification
3. Statement of Identity Theft
4. Fraudulent Accounts and Charges Schedule
5. Source / Suspected Source of Theft
6. Persons Authorized to Use Identity (None)
7. Affirmative Statements and Acknowledgments
8. Verification and Notarization
9. Police Report Cover Letter
10. FCRA Blocking and Furnisher Demand Cover (separate mailing)
11. Distribution Checklist
12. Minnesota Practice Notes
13. Sources and References

1. IDENTITY THEFT AFFIDAVIT — CAPTION AND OATH

STATE OF MINNESOTA

COUNTY OF [COUNTY]

AFFIDAVIT OF IDENTITY THEFT

I, [VICTIM FULL LEGAL NAME], being first duly sworn under oath, depose and say:

2. VICTIM IDENTIFICATION

3. STATEMENT OF IDENTITY THEFT

3.1. I am the victim of identity theft within the meaning of Minn. Stat. § 609.527 and 15 U.S.C. § 1681a(q)(3).

3.2. Some person or persons, whose identity is presently [unknown / known to me as [NAME]], has transferred, possessed, or used my "identity" — meaning my name, Social Security number, date of birth, government-issued identification number, account number, or other identifying data — without my consent, with the intent to commit, aid, or abet unlawful activity, in violation of Minn. Stat. § 609.527.

3.3. I have not authorized any person to use my identity for the transactions described in Section 4 below, and I have not received any goods, services, money, or other benefit from those transactions.

3.4. I first became aware of the identity theft on [__/__/____] when [DESCRIBE — e.g., I received a collection letter from [COLLECTOR]; I received a credit-card statement for an account I did not open; my credit report showed accounts I do not recognize; I was notified of a data breach by [ENTITY]].

3.5. I have [contacted / will contact within 7 days] each of the three nationwide consumer reporting agencies (Equifax, Experian, TransUnion) and placed an initial fraud alert under 15 U.S.C. § 1681c-1.

4. FRAUDULENT ACCOUNTS AND CHARGES SCHEDULE

I declare under penalty of perjury that none of the accounts or transactions listed above were authorized by me, and that I received no benefit from any of them.

5. SOURCE / SUSPECTED SOURCE OF THEFT

5.1. ☐ The source of the identity theft is unknown to me.

5.2. ☐ I received a Minnesota data-breach notification under Minn. Stat. § 325E.61 from [ENTITY NAME] dated [__/__/____], attached as Exhibit [__], and I believe the breach is the source of the theft.

5.3. ☐ I lost or had stolen the following items containing identifying information on [__/__/____]: [wallet / purse / mail / device — describe].

5.4. ☐ I believe the perpetrator is or may be [NAME], a [relationship — e.g., former roommate, family member], based on [FACTS].

5.5. ☐ Other: [DESCRIBE].

6. PERSONS AUTHORIZED TO USE IDENTITY (NONE)

6.1. No person is authorized to obtain credit, open accounts, file tax returns, or otherwise use my identity for any of the transactions described in Section 4.

6.2. I do not have a power-of-attorney, joint-account, or guardianship arrangement that would authorize any of the listed transactions.

7. AFFIRMATIVE STATEMENTS AND ACKNOWLEDGMENTS

7.1. No personal benefit. I did not authorize any of the fraudulent transactions and received no funds, goods, or services from any of them.

7.2. Cooperation with law enforcement. I will cooperate with all reasonable law-enforcement requests for information.

7.3. Truth and accuracy. All statements in this Affidavit are true and accurate to the best of my knowledge and belief. I understand that knowingly making a false statement to a credit reporting agency or in furtherance of a fraudulent claim is unlawful.

7.4. Authorization. I authorize the recipient(s) of this Affidavit to (a) close the fraudulent accounts; (b) cease all collection activity related to the fraudulent accounts; (c) block the disputed tradelines from my consumer reports under 15 U.S.C. § 1681c-2; and (d) furnish updated information to consumer reporting agencies reflecting the fraud.

8. VERIFICATION AND NOTARIZATION

I declare under penalty of perjury under the laws of the State of Minnesota and the United States that the foregoing is true and correct.

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

[________________________________]

[VICTIM FULL LEGAL NAME]

STATE OF MINNESOTA

COUNTY OF [COUNTY]

Sworn to (or affirmed) and subscribed 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

(My Commission Expires: [_______________])

9. POLICE REPORT COVER LETTER

TO: [NAME OF POLICE / SHERIFF AGENCY]

ATTN: Records Division / Investigations / Financial Crimes Unit

[STREET ADDRESS]

[CITY, MN ZIP]

Date: [__/__/____]

RE: Request to File Identity Theft Report — Minn. Stat. § 609.527

Dear Officer / Detective:

I am a resident of [CITY, COUNTY], Minnesota, and a victim of identity theft as defined by Minn. Stat. § 609.527. I respectfully request that your agency take a formal police report of this offense so that I may use the report number, together with my sworn FTC Identity Theft Affidavit (attached), as an "Identity Theft Report" within the meaning of 16 C.F.R. § 603.3.

The Identity Theft Report is required to obtain (i) extended fraud alerts under 15 U.S.C. § 1681c-1; (ii) blocking of fraudulent tradelines under 15 U.S.C. § 1681c-2; and (iii) cessation of furnishing of fraudulent information under 15 U.S.C. § 1681s-2(a)(6)(B).

The following documents are enclosed:

• Sworn Identity Theft Affidavit (notarized)
• FTC IdentityTheft.gov Report (printed)
• Schedule of fraudulent accounts and charges
• Copies of fraudulent account statements / notices (Exhibits [__] through [__])
• Copy of any data-breach notification received under Minn. Stat. § 325E.61 (if applicable)
• Government-issued photo ID
• Proof of current Minnesota residence

Please provide me with a stamped copy of the police report and the report case number. I am willing to be interviewed at your convenience and to assist any investigation.

Sincerely,

[________________________________]

[VICTIM NAME]

10. FCRA BLOCKING AND FURNISHER DEMAND COVER (SEPARATE MAILING)

(Send to each Consumer Reporting Agency and to each Furnisher of disputed information)

TO: [CRA OR FURNISHER NAME]

ATTN: Identity Theft / FCRA Compliance

[ADDRESS]

Date: [__/__/____]

RE: Identity Theft Block Request under 15 U.S.C. § 1681c-2 / Furnisher Cease Request under 15 U.S.C. § 1681s-2(a)(6)(B)

I am a victim of identity theft. Pursuant to 15 U.S.C. § 1681c-2, I demand that you BLOCK the following items of information that resulted from identity theft from my consumer file within four (4) business days of receipt of this notice:

Enclosed are the items required by 15 U.S.C. § 1681c-2(a):

• (1) Identity Theft Report — my notarized Identity Theft Affidavit and the Minnesota police report (Case No. [CASE NO.]);
• (2) Identification of information — the tradelines listed above;
• (3) Statement — I declare under penalty of perjury that the listed information does not relate to any transaction by me;
• (4) Proof of identity — copy of my Minnesota driver's license / state ID and proof of current address.

For each furnisher recipient: pursuant to 15 U.S.C. § 1681s-2(a)(6)(B), you are also required to cease furnishing the disputed information to any consumer reporting agency unless you subsequently determine the information is correct. Please confirm in writing within thirty (30) days.

Sincerely,

[________________________________]

[VICTIM NAME]

11. DISTRIBUTION CHECKLIST

☐ FTC IdentityTheft.gov — online complaint filed; report number obtained

☐ Local Minnesota police / sheriff — in-person report filed; case number obtained

☐ Equifax — Block letter sent (P.O. Box 105069, Atlanta, GA 30348)

☐ Experian — Block letter sent (P.O. Box 9554, Allen, TX 75013)

☐ TransUnion — Block letter sent (P.O. Box 2000, Chester, PA 19016)

☐ Each fraudulent-account furnisher — Block + cease-furnishing letter sent

☐ Social Security Administration (if SSN used) — https://www.ssa.gov/

☐ IRS Form 14039 (if tax return filed) — https://www.irs.gov/forms-pubs/about-form-14039

☐ U.S. Postal Inspection Service (if mail involved) — https://www.uspis.gov/

☐ Minnesota Attorney General Consumer Assistance Request — filed

☐ State of Minnesota — driver's license / ID flagged with DPS-DVS if applicable

☐ Minnesota BCA (if local law enforcement declines or for cross-jurisdictional cases)

12. MINNESOTA PRACTICE NOTES

• Criminal statute reference. Minnesota's identity-theft offense (Minn. Stat. § 609.527) is graded by amount of loss and number of victims; charges escalate from misdemeanor through 20-year felony for losses exceeding $35,000 or eight or more direct/indirect victims. Reference this in the police-report cover letter to encourage proper case routing.
• Direct vs. indirect victim. Minn. Stat. § 609.527, subd. 1 distinguishes "direct" and "indirect" victims. Both may seek restitution; the consumer is typically the "direct victim."
• Data-breach overlay. Minn. Stat. § 325E.61 requires entities holding unencrypted personal information of Minnesotans to notify affected consumers without unreasonable delay following discovery of a breach. If the theft is breach-related, attach the § 325E.61 notice to the affidavit and reference the breach number, if any. The Minnesota AG enforces § 325E.61.
• Public-sector breaches. For breaches at state or local government entities, the analog is Minn. Stat. § 13.055.
• FCRA Identity Theft Report. 16 C.F.R. § 603.3 requires the consumer to provide both (i) a copy of an official report filed with a federal, state, or local law-enforcement agency and (ii) a "subject-to-penalty-of-perjury" statement of identity theft. The FTC IdentityTheft.gov report combined with a local Minnesota police report satisfies both prongs.
• Notarization. Minnesota recognizes both traditional notarization and electronic remote notarization (Minn. Stat. ch. 358). Verify that the recipient (creditor / CRA) accepts electronic notarization before relying on it.
• Statute of limitations on civil claims. A consumer's civil claim against a furnisher under FCRA § 1681s-2(b) accrues on discovery and must be brought within two years of discovery and not later than five years after the violation, 15 U.S.C. § 1681p.

13. SOURCES AND REFERENCES

• Minn. Stat. § 609.527 — https://www.revisor.mn.gov/statutes/cite/609.527
• Minn. Stat. § 325E.61 — https://www.revisor.mn.gov/statutes/cite/325E.61
• Minn. Stat. § 13.055 — https://www.revisor.mn.gov/statutes/cite/13.055
• Minn. Stat. § 611A.01 — https://www.revisor.mn.gov/statutes/cite/611A.01
• 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 ID theft information) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 16 C.F.R. § 603.3 (Identity Theft Report definition) — https://www.ecfr.gov/current/title-16/chapter-I/subchapter-F/part-603
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• IRS Form 14039 — https://www.irs.gov/forms-pubs/about-form-14039
• Minnesota AG, Guarding Your Privacy — https://www.ag.state.mn.us/consumer/handbooks/GuardingYPrivacy/CH2.asp
• Minnesota BCA — https://dps.mn.gov/divisions/bca/

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