Identity Theft Affidavit and Police Report Cover (Missouri)

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — MISSOURI

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

1. AFFIANT INFORMATION

2. SWORN STATEMENT OF IDENTITY THEFT

STATE OF MISSOURI

COUNTY 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, and I am over the age of 18 and 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 in Missouri by RSMo § 570.223.

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, data breach notification under RSMo § 407.1500].

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] 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; (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; and (v) supporting any criminal investigation, prosecution, restitution proceeding under RSMo § 570.223.4, or civil action for damages under RSMo § 570.223.5.

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 (driver's license, passport, Missouri non-driver ID).

☐ Exhibit 3. Proof of 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. Data breach notification(s) received under RSMo § 407.1500, if applicable.

☐ Exhibit 9. Other: [describe].

5. COVER LETTER TO LAW ENFORCEMENT AGENCY

[DATE]

[LAW ENFORCEMENT AGENCY NAME]

Attn: Records Division / Identity Theft Unit / Fraud Detective

[STREET ADDRESS]

[CITY, MO ZIP]

RE: Request to File a Police Report — Identity Theft Victim — RSMo § 570.223

Dear Officer / Records Division:

I am a Missouri resident and the victim of identity theft as criminalized by RSMo § 570.223. I respectfully request that your agency take this report so that I may obtain an "Identity Theft Report" sufficient under 15 U.S.C. § 1681a(q)(4) and 16 C.F.R. § 603.3 for use with consumer reporting agencies and creditors.

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 Missouri address (Exhibit 3);
• Supporting documentation of fraudulent activity (Exhibit 4);
• Copies of my consumer credit reports with disputed items marked (Exhibit 5);
• Any data breach notification(s) received under RSMo § 407.1500 (Exhibit 8, if applicable).

I respectfully request:

1. That your agency open an incident or case report and provide me a report number and a certified copy of the report when available;
2. That investigative referrals be made, where warranted, to the Missouri Highway Patrol Division of Drug and Crime Control, the Missouri Attorney General's Office, the U.S. Postal Inspection Service, the U.S. Secret Service, the FBI, or other appropriate agency;
3. That a copy of the report be flagged for any subsequent restitution proceeding under RSMo § 570.223.4 or civil action under RSMo § 570.223.5.

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, this [____] day of [_______________], 20[____].

[________________________________]

Notary Public

State of Missouri, County of [______________]

My commission expires: [__/__/____]

(Notary Seal)

7. DISTRIBUTION LIST

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

8. MISSOURI PRACTICE NOTES

• Civil right of action under RSMo § 570.223.5. Missouri provides a private civil cause of action against any person who commits identity theft, with damages of up to $5,000 per incident or three times actual damages, whichever is greater, plus reasonable attorney's fees. The statute also allows recovery of consequential damages such as lost time, postage, and credit-monitoring costs. The civil action must be brought within five (5) years from the date the identity of the wrongdoer was discovered or reasonably should have been discovered (RSMo § 570.223.7).
• Criminal classification. Identity theft is a misdemeanor or felony under RSMo § 570.223 depending on the value involved (Class B misdemeanor for no theft; Class A misdemeanor up to $750; Class E felony for repeat offense $750 or less; Class D felony for $750 to $25,000; Class C felony for $25,000 to $75,000; Class B felony for $75,000 or more, per the most recent statutory amendment). Restitution to the victim is authorized under RSMo § 570.223.4.
• Trafficking in stolen identities. RSMo § 570.224 separately criminalizes the manufacture, sale, transfer, or possession of multiple means of identification (5+) with intent to defraud — useful where the conduct extends beyond a single victim.
• Missouri data breach notification — RSMo § 407.1500. Any business that owns or licenses computerized personal information of Missouri residents must notify affected consumers of any breach of security, and, if more than 1,000 Missouri residents are affected, must also notify the Missouri Attorney General and all nationwide consumer reporting agencies. Notice may be delayed only at the request of law enforcement. The AG has enforcement authority and may seek civil penalties and damages on behalf of consumers under RSMo § 407.1500.4. Document any breach notice received and attach it to the affidavit; consider a parallel AG complaint.
• 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.
• Security freeze. Federal law (15 U.S.C. § 1681c-1) authorizes free security freezes for any consumer. Place freezes with all three nationwide CRAs to prevent new-account fraud while disputes are pending. Missouri provides additional consumer remedies under RSMo § 407.1500.
• Missouri tax identity theft. If the affiant suspects fraudulent Missouri state tax filings, contact the Missouri Department of Revenue's Identity Theft Unit. For federal tax fraud, 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.
• Coordination with collection defense. If a fraudulent debt is in collection, send the FDCPA debt validation letter (with this affidavit attached) and assert identity-theft as a complete defense. Demand the collector cease collection under FDCPA § 1692c and § 1692e(8), and instruct CRAs to delete the tradeline.

9. SOURCES AND REFERENCES

• RSMo § 570.223 (Identity theft — penalty, restitution, civil remedies) — https://revisor.mo.gov/main/OneSection.aspx?section=570.223
• RSMo § 570.224 (Trafficking in stolen identities) — https://revisor.mo.gov/main/OneSection.aspx?section=570.224
• RSMo § 407.1500 (Data breach notification) — https://revisor.mo.gov/main/OneSection.aspx?section=407.1500
• 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/
• Missouri Attorney General — Identity Theft & Data Security — https://ago.mo.gov/civil-division/consumer/identity-theft-data-security/
• Missouri AG Data Breach Reporting — https://ago.mo.gov/civil-division/consumer/identity-theft-data-security/data-breaches
• Missouri Department of Revenue — https://dor.mo.gov

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