Identity Theft Affidavit and Police Report Cover (Mississippi)

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — MISSISSIPPI

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. Mississippi Practice Notes
9. Sources and References

1. AFFIANT INFORMATION

2. SWORN STATEMENT OF IDENTITY THEFT

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

2.1. I am a resident of [CITY], [COUNTY] County, Mississippi. I make this affidavit on personal knowledge.

2.2. On or about [DATE], I discovered that one or more persons, unknown to me, fraudulently used my identifying information — including my [name / Social Security number / date of birth / driver's license / financial account number / other] — to obtain credit, goods, services, or other things of value, without my knowledge, authority, or consent.

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

2.4. I do not have and have never had any business or contractual relationship with the creditors and entities identified in Schedule A other than as a victim of the unauthorized use of my identifying information.

2.5. I believe that the conduct described constitutes identity theft as defined by 15 U.S.C. § 1681a(q)(3) and one or more violations of Miss. Code Ann. § 97-19-85 (fraudulent use of identity, Social Security number, credit card or debit card number, or other identifying information to obtain a thing of value), and Miss. Code Ann. § 97-45-19 (identity theft).

2.6. I request that the receiving law enforcement agency (a) accept and file this affidavit as a police report, (b) issue a report number and provide me a certified copy, and (c) cooperate with any subsequent investigation by the Mississippi Attorney General's office under Miss. Code Ann. § 97-45-2 or by federal authorities.

2.7. I make this affidavit for the purposes of (a) obtaining a police report constituting an "Identity Theft Report" under 15 U.S.C. § 1681a(q)(4) and 16 C.F.R. § 603.3, (b) blocking fraudulent tradelines under 15 U.S.C. § 1681c-2, (c) obtaining application records from creditors under 15 U.S.C. § 1681g(e), (d) supporting any future claim for restitution under Miss. Code Ann. § 99-37-1 et seq., and (e) supporting any complaint to the Mississippi Attorney General's Consumer Protection Division and the U.S. Federal Trade Commission.

2.8. I understand that knowingly making a false statement to a law enforcement officer or in a sworn affidavit is a criminal offense under Mississippi and federal law.

3. SCHEDULE A — FRAUDULENT ACCOUNTS AND TRANSACTIONS

4. SCHEDULE B — DOCUMENTS ATTACHED

• ☐ FTC IdentityTheft.gov affidavit (printed PDF) and FTC report number [____________]
• ☐ Government-issued photo ID (front and back)
• ☐ Proof of address (utility bill, lease, or bank statement dated within 60 days)
• ☐ Credit reports from Equifax, Experian, and TransUnion (with fraudulent items circled)
• ☐ Fraud alert / security freeze confirmation letters from each CRA
• ☐ Collection letters, monthly statements, or denial-of-credit notices showing the fraudulent accounts
• ☐ IRS notice (Form 14039 if tax-related identity theft)
• ☐ Mississippi Department of Employment Security correspondence (if unemployment fraud)
• ☐ Any breach-notification letter received under Miss. Code Ann. § 75-24-29 or other state law
• ☐ Other: [DESCRIBE]

5. COVER LETTER TO LAW ENFORCEMENT AGENCY

Date: [__/__/____]

[POLICE DEPARTMENT / SHERIFF'S OFFICE NAME]

Attn: Records / Identity Theft Unit

[STREET ADDRESS]

[CITY, MS ZIP]

Re: Identity Theft Report — Affiant [AFFIANT FULL NAME]

To the Records Custodian:

I am a resident of [CITY, COUNTY] County, Mississippi, and a victim of identity theft. The conduct described in the attached sworn affidavit and Schedule A constitutes one or more violations of Miss. Code Ann. § 97-19-85 (fraudulent use of identity / SSN / credit-card / other identifying information) and Miss. Code Ann. § 97-45-19 (identity theft).

I respectfully request that your agency:

1. Accept and file this affidavit and its attachments as a formal police report;
2. Issue a report number and provide me a certified copy of the report;
3. Investigate the matters described, refer the matter to the Mississippi Attorney General's office (Consumer Protection / Cybercrime Unit) under Miss. Code Ann. § 97-45-2 if appropriate, and coordinate with federal authorities (FBI / U.S. Secret Service / FTC) if interstate or large-loss elements are present.

I understand that the certified police report (together with my FTC IdentityTheft.gov affidavit) qualifies as an "Identity Theft Report" under 15 U.S.C. § 1681a(q)(4) and 16 C.F.R. § 603.3 and is required to obtain mandatory blocking of fraudulent items under 15 U.S.C. § 1681c-2.

Thank you for your assistance.

[________________________________]

[AFFIANT NAME]

[PHONE / EMAIL]

6. NOTARIZATION AND VERIFICATION

STATE OF MISSISSIPPI

COUNTY OF [COUNTY]

I, [AFFIANT NAME], having been duly sworn, state under penalty of perjury under the laws of the State of Mississippi and the United States that the foregoing affidavit and Schedules A and B are true and correct to the best of my knowledge and belief.

[________________________________]

[AFFIANT NAME]

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public

(My Commission Expires: [_______________])

[NOTARY SEAL]

7. DISTRIBUTION LIST

8. MISSISSIPPI PRACTICE NOTES

• Two parallel criminal statutes. Mississippi prosecutes identity-theft conduct under both Miss. Code Ann. § 97-19-85 (fraudulent use of identifying information to obtain a thing of value — Title 97 / Crimes) and Miss. Code Ann. § 97-45-19 (identity theft, within the Computer Crimes and Identity Theft chapter). § 97-19-85 carries felony exposure of up to five years and a $5,000 fine for a first offense, and up to ten years and a $10,000 fine for a second or subsequent offense. Restitution is mandatory under Miss. Code Ann. § 99-37-1 et seq. § 97-45-19 carries similar penalties and is the principal vehicle for prosecuting computer-based identity theft.
• AG investigative authority. The Mississippi Attorney General has subpoena power and investigative authority over identity-theft cases under Miss. Code Ann. § 97-45-2. A police-report-and-affidavit referral to the AG's Cyber Crime Unit (601-359-3680) is often more effective than waiting on a small municipal department to investigate.
• No private right under the data-breach statute. Miss. Code Ann. § 75-24-29 requires breach notification but expressly provides no private right of action; the AG enforces violations as unfair trade practices. Where identity theft is traceable to a particular breach, civil recovery against the breached entity will typically depend on (a) common-law negligence theories, (b) federal causes of action (FCRA, ECPA, CFAA), or (c) participation in a multistate class action filed under another state's private-right statute.
• Police-report acceptance. Mississippi law does not codify a residential-jurisdiction right to file an identity-theft police report (compare Georgia O.C.G.A. § 16-9-129). Most agencies will accept reports as a matter of policy, but there is no statutory enforcement mechanism. If declined, escalate to the AG, MBI, or federal authorities.
• FCRA-required Identity Theft Report. A police report alone does not unlock FCRA § 1681c-2 blocking; pair the police report with the FTC IdentityTheft.gov affidavit. The FTC affidavit substitutes a federal-agency self-report for the local-agency variability. The combination satisfies 16 C.F.R. § 603.3.
• Tax-related identity theft. File IRS Form 14039 in addition to local police report. Mississippi Department of Revenue accepts identity-theft notifications for state tax fraud at (601) 923-7700.
• Unemployment-fraud identity theft. During and after the pandemic, large numbers of Mississippi residents experienced unemployment-fraud identity theft. Report to the Mississippi Department of Employment Security (601-321-6000) in addition to local police and the AG.
• Civil restitution. Restitution under Miss. Code Ann. § 99-37-1 is part of the criminal sentence; it is not a substitute for a private civil action. Where the identity thief is identified and judgment-collectible, a separate civil suit (conversion, fraud, common-law identity theft) is appropriate and not subject to the MCPA's BBB-mediation prerequisite, which applies only to claims under the MCPA itself.
• Statute of limitations. Felony prosecutions under § 97-19-85 and § 97-45-19 are governed by the residual two-year limitations of Miss. Code Ann. § 99-1-5, with exceptions for certain enumerated felonies (which generally do not apply here). Civil identity-theft claims are typically governed by the three-year period of Miss. Code Ann. § 15-1-49.
• Redact full SSN before distribution to creditors. Provide full SSN only to law enforcement and the three nationwide CRAs. All other distribution should use last-four redaction to limit re-victimization risk.

9. SOURCES AND REFERENCES

• Miss. Code Ann. § 97-19-85 (Fraudulent use of identity, SSN, credit card) — https://law.justia.com/codes/mississippi/title-97/chapter-19/section-97-19-85/
• Miss. Code Ann. § 97-45-19 (Identity theft) — https://law.justia.com/codes/mississippi/title-97/chapter-45/section-97-45-19/
• Miss. Code Ann. § 97-45-2 (AG investigative authority) — https://law.justia.com/codes/mississippi/title-97/chapter-45/
• Miss. Code Ann. § 99-37-1 et seq. (Restitution) — https://law.justia.com/codes/mississippi/title-99/chapter-37/
• Miss. Code Ann. § 75-24-29 (Data Breach Disclosure) — https://codes.findlaw.com/ms/title-75-regulation-of-trade-commerce-and-investments/ms-code-sect-75-24-29/
• 15 U.S.C. § 1681a(q) (FCRA — identity theft definitions) — 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 identity-theft information) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 15 U.S.C. § 1681g(e) (Disclosure to victim) — https://www.law.cornell.edu/uscode/text/15/1681g
• 16 C.F.R. § 603.3 (Identity Theft Report) — https://www.ecfr.gov/current/title-16/chapter-I/subchapter-F/part-603
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• Mississippi Attorney General — Consumer Protection Division — https://attorneygenerallynnfitch.com/divisions/consumer-protection/
• Mississippi Attorney General — Cyber Crime Unit — https://www.ago.state.ms.us/
• IRS Identity Theft Resources / Form 14039 — https://www.irs.gov/identity-theft-fraud-scams
• AnnualCreditReport.com — https://www.annualcreditreport.com/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Mississippi should review and customize this affidavit before use, particularly in cases involving large dollar amounts, suspected insider participation, or breach-related fraud. Laws, citations, and agency procedures change frequently; verify all authorities before filing.