Identity Theft Affidavit and Police Report Cover - New Hampshire

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — NEW HAMPSHIRE

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. New Hampshire Practice Notes
7. Sources and References

1. POLICE REPORT COVER LETTER

[VICTIM FULL LEGAL NAME]

[STREET ADDRESS]

[CITY, NH ZIP]

Telephone: [________________]

Email: [________________]

Date: [__/__/____]

[POLICE DEPARTMENT NAME]

Attn: Records / Identity Theft / Financial Crimes Unit

[STREET ADDRESS]

[CITY, NH ZIP]

Re: Request to File Identity Theft Police Report Under RSA 638:26 (Identity Fraud)

Dear Officer in Charge:

I am a resident of [CITY, COUNTY], New Hampshire, 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 RSA 638:26 (Identity Fraud), which is a Class A felony in New Hampshire. Under RSA 638:26, V, a New Hampshire law-enforcement agency has jurisdiction whenever any act in furtherance occurred in New Hampshire or any victim of the offense resides in New Hampshire. As a New Hampshire resident, 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, the New Hampshire Attorney General's Consumer Protection and Antitrust Bureau, and federal regulators;
3. That the report identify, where known, each fraudulent account, transaction, or use of my identifying information;
4. That a copy of the report be transmitted, where appropriate, to the New Hampshire Attorney General, the New Hampshire State Police, and any out-of-state agency in whose jurisdiction acts in furtherance occurred; and
5. That, if the alleged perpetrator is known to me, I be informed of the steps that will be taken and that the prosecutor be advised that I will request mandatory restitution under RSA 638:26, III if charges are filed.

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 NEW HAMPSHIRE

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, NH 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 identity fraud as defined by RSA 638:26. 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, or has posed as me with the purpose of obtaining confidential information about me that is not available to the general public.

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; received RSA 359-C:20 data-breach notice].

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 RSA 359-C:20 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 RSA 359-B:24 on [__/__/____]. As a victim of identity theft submitting a copy of this police report, I am entitled to a security freeze at NO CHARGE under RSA 359-B:24, IV.

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 notified, where applicable, the New Hampshire Attorney General's Consumer Protection and Antitrust Bureau (1 Granite Place South, Concord, NH 03301; (603) 271-3658).

C.6. 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 (RSA 641:3) or perjury (RSA 641:1).

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: New Hampshire 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.

The undersigned also requests, pursuant to RSA 359-B:24, a security freeze on the undersigned's consumer report at NO CHARGE based on the enclosed police report (RSA 359-B:24, IV — fee waiver for identity-theft victims).

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 NEW HAMPSHIRE

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 / Justice of the Peace / Attorney-at-Law (RSA 456-B)

Print Name: [________________________________]

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

[NOTARY SEAL]

6. NEW HAMPSHIRE PRACTICE NOTES

• Right to a police report. RSA 638:26 (Identity Fraud) is a Class A felony. NH law enforcement has jurisdiction whenever any act in furtherance occurred in NH OR any victim resides in NH (RSA 638:26, V). If your local department refuses to take a report, escalate to the NH State Police Major Crime Unit or the NH AG's Consumer Protection and Antitrust Bureau ((603) 271-3658). A police report is essential to obtain an FCRA § 1681c-2 block AND to qualify for the free RSA 359-B:24 security freeze.
• Mandatory restitution. RSA 638:26, III mandates that a person convicted of identity fraud "be ordered to make restitution for economic loss sustained by a victim as a result of such violation." Document all economic losses, attorney fees, time off work, and out-of-pocket expenses for the restitution petition.
• 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 New Hampshire police report — many creditors require both, and only the police report unlocks the free RSA 359-B:24 freeze.
• Free security freeze for victims. Under RSA 359-B:24, IV, a CRA "shall not charge a fee" to an identity-theft victim for placing, removing, or temporarily lifting a security freeze when the victim submits a copy of the police report. Non-victims may be charged up to $10. Federal law (15 U.S.C. § 1681c-1) now also makes freezes free nationwide; cite both.
• Data-breach overlay. RSA 359-C:19 defines "security breach" as unauthorized acquisition of computerized personal information. RSA 359-C:20 requires breach notification to affected NH residents AND, for non-trade/commerce entities, to the NH Attorney General. RSA 359-C:21 makes violations enforceable as unfair or deceptive practices under RSA 358-A — meaning an injured consumer has a private right of action under RSA 358-A:10 with mandatory 2x-3x enhanced compensatory damages for willful violations, plus mandatory attorney's fees.
• No common-law punitives. Vratsenes v. N.H. Auto, Inc., 112 N.H. 71 (1972) bars common-law punitive damages. Civil exposure for the breached entity flows through RSA 358-A:10 (statutory enhancement) and RSA 359-C:21, not through punitive damages.
• Tax-related identity theft. File IRS Form 14039 (Identity Theft Affidavit) and notify the New Hampshire Department of Revenue Administration if state tax filings are affected. (NH does not have a general personal income tax but does tax interest, dividends, and certain business income.) 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. NH-licensed providers also have RSA 332-I, 7 obligations regarding patient records.
• 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 affidavit of factual innocence and ensure NCIC records are updated.
• 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 an RSA 358-A claim for unfair or deceptive practices, with the mandatory enhancement under RSA 358-A:10, II.
• 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. Renew the fraud alert annually if not converted to a freeze.

7. SOURCES AND REFERENCES

• RSA 638:26 (Identity Fraud) — https://gc.nh.gov/rsa/html/lxii/638/638-26.htm
• RSA 359-C:19 (Security Breach Definitions) — https://gc.nh.gov/rsa/html/nhtoc/nhtoc-xxxi-359-c.htm
• RSA 359-C:20 (Notification of Security Breach Required) — https://gc.nh.gov/rsa/html/nhtoc/nhtoc-xxxi-359-c.htm
• RSA 359-C:21 (Violations enforceable under RSA 358-A) — https://gc.nh.gov/rsa/html/nhtoc/nhtoc-xxxi-359-c.htm
• RSA 359-B:24 (Security Freeze) — https://gc.nh.gov/rsa/html/nhtoc/nhtoc-xxxi-359-b.htm
• RSA 358-A:10 (Private actions; enhanced damages) — https://gc.nh.gov/rsa/html/xxxi/358-A/358-A-10.htm
• 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
• NH AG Consumer Protection and Antitrust Bureau — https://www.doj.nh.gov/citizens/consumer-protection-antitrust-bureau
• NH AG Security Breach Notifications — https://www.doj.nh.gov/citizens/consumer-protection-antitrust-bureau/security-breach-notifications
• New Hampshire State Police — https://www.dos.nh.gov/state-police
• IRS Form 14039 — https://www.irs.gov/forms-pubs/about-form-14039
• Vratsenes v. N.H. Auto, Inc., 112 N.H. 71 (1972)

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