Identity Theft Affidavit and Police Report Cover Letter - New York

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER LETTER — NEW YORK

New York provides robust identity theft protections through a graduated criminal penalty structure (Penal Law § 190.77-190.84), the SHIELD Act (GBL § 899-aa and 899-bb) for data breach notification and security requirements, and comprehensive credit freeze provisions (GBL § 380-s). New York also operates an identity theft passport program through the NYS Division of Consumer Protection.

PART A: FTC IDENTITY THEFT REPORT INSTRUCTIONS

Step 1: File an FTC Identity Theft Report

The Federal Trade Commission (FTC) provides a centralized identity theft reporting system at IdentityTheft.gov.

Procedure:

1. Visit https://IdentityTheft.gov
2. Create an account (recommended) or proceed without one
3. Answer questions about the identity theft incident
4. Receive your Identity Theft Report and personalized recovery plan
5. Print and save the Identity Theft Report — you will need copies for creditors, CRAs, and law enforcement

Current IRS note: Form 14039 is an IRS tax-identity-theft form. Most
people do not need it. Use it only when the current IRS instructions direct
or permit filing:
https://www.irs.gov/identity-theft-fraud-scams/identity-theft-guide-for-individuals#form14039.

Step 2: Contact the Three Major Credit Reporting Agencies

Use the FTC current bureau directory at
https://consumer.ftc.gov/articles/credit-freezes-and-fraud-alerts. Verify each
bureau's current recipient, address, and submission channel immediately before
sending; do not rely on saved phone numbers or postal addresses.

Step 3: Place Fraud Alerts

Initial Fraud Alert (1 Year):

• Contact ONE CRA; that agency must notify the other two
• Lasts 1 year
• Requires creditors to take reasonable steps to verify identity before opening new accounts

Extended Fraud Alert (7 Years):

• Available to confirmed identity theft victims with an Identity Theft Report
• Lasts 7 years
• Requires creditors to contact the consumer directly before opening new accounts
• Consumer is removed from pre-screened credit offer lists for 5 years

Step 4: Place Security Freezes

Under federal law, security freezes are free nationwide. New York also has its own security freeze statute.

New York Security Freeze Provisions (GBL § 380-s):

• Consumers may place, temporarily lift, or permanently remove a security freeze at no cost
• CRA must place freeze within 1 business day of electronic request or 3 business days of request by mail
• To temporarily lift the freeze, the CRA must act within 1 business day of electronic request or 3 business days of request by mail
• The freeze prohibits the CRA from releasing the consumer's credit report without express authorization
• New York law requires CRAs to provide written confirmation of the freeze within 5 business days

Step 5: New York Identity Theft Passport Program

New York operates an identity theft passport program through the NYS Division of Consumer Protection:

• Purpose: Provides identity theft victims with an official document to present to law enforcement to help prevent wrongful arrest or detention
• How to Apply: Contact the NYS Division of Consumer Protection at (800) 697-1220
• Documentation Required: Police report, FTC Identity Theft Report, government-issued ID, proof of address
• Benefit: Creates an official state record of victim status that can be used with law enforcement, creditors, and CRAs

PART B: IDENTITY THEFT AFFIDAVIT

SECTION 1: VICTIM INFORMATION

Full Legal Name: [________________________________]

Former/Maiden/Other Names Used: [________________________________]

Date of Birth: [__/__/____]

Social Security Number: [____] - [____] - [____]

Current Address:

Street: [________________________________]

City: [________________________________] State: NY ZIP: [____]

How long at this address? [________________________________]

Previous Address (if at current address less than 2 years):

Street: [________________________________]

City: [________________________________] State: [____] ZIP: [____]

Home Phone: [________________________________]

Work Phone: [________________________________]

Cell Phone: [________________________________]

Email Address: [________________________________]

New York Driver's License Number: [________________________________]

New York Non-Driver ID Number (if applicable): [________________________________]

SECTION 2: FRAUDULENT ACCOUNT INFORMATION

Complete one entry for each fraudulent account. Attach additional pages if necessary.

Fraudulent Account #1

Fraudulent Account #2

Fraudulent Account #3

(Attach additional pages using the same format for additional fraudulent accounts.)

SECTION 3: HOW THE IDENTITY THEFT OCCURRED

How did you first discover the identity theft?

[________________________________]
[________________________________]
[________________________________]

When did the identity theft first occur (or your best estimate)? [__/__/____]

When did you first discover the identity theft? [__/__/____]

Do you know or suspect how the identity thief obtained your personal information?

☐ Lost or stolen wallet/purse
☐ Lost or stolen mail
☐ Data breach notification received (Company: [________________________________])
☐ Stolen from home, car, or office
☐ Someone I know had access to my information
☐ Phishing email or phone scam
☐ Online data compromise
☐ Medical or insurance records theft
☐ Tax-related identity theft
☐ Unknown
☐ Other: [________________________________]

SECTION 4: KNOWN OR SUSPECTED PERPETRATOR INFORMATION

Do you know or suspect who committed the identity theft?

☐ No — Skip to Section 5
☐ Yes — Complete below

Suspected Perpetrator's Name: [________________________________]

Relationship to Victim: [________________________________]

Last Known Address: [________________________________]

Phone Number: [________________________________]

Other Identifying Information: [________________________________]

Why do you suspect this person?

[________________________________]
[________________________________]

SECTION 5: TIMELINE OF EVENTS AND ACTIONS TAKEN

SECTION 6: ACTIONS ALREADY TAKEN

☐ Filed FTC Identity Theft Report at IdentityTheft.gov — Report Number: [________________________________]
☐ Filed police report — Agency: [________________________________] Report Number: [________________________________]
☐ Placed initial fraud alert (1-year) with: ☐ Equifax ☐ Experian ☐ TransUnion — Date: [__/__/____]
☐ Placed extended fraud alert (7-year) — Date: [__/__/____]
☐ Placed security freeze with: ☐ Equifax ☐ Experian ☐ TransUnion — Date: [__/__/____]
☐ Requested free credit reports from all three CRAs
☐ Contacted affected creditors/financial institutions
☐ Contacted debt collectors regarding fraudulent debts
☐ Applied for NY Identity Theft Passport (Division of Consumer Protection)
☐ Filed complaint with NYS Attorney General
☐ Filed complaint with NYS Department of Financial Services (DFS)
☐ Filed IRS Identity Theft Affidavit (IRS Form 14039 only if current IRS instructions call for it) — if tax-related
☐ Contacted Social Security Administration — if SSN compromised
☐ Contacted U.S. Postal Inspection Service — if mail theft involved
☐ Changed passwords and PINs on all accounts
☐ Other: [________________________________]

SECTION 7: DECLARATION UNDER PENALTY OF PERJURY

I, [________________________________], declare under penalty of perjury under the laws of the United States and the State of New York that the information provided in this affidavit is true and correct to the best of my knowledge. I understand that knowingly making false statements in this affidavit may subject me to criminal prosecution under 18 U.S.C. § 1001 (false statements to federal agencies) and N.Y. Penal Law § 210.05 (perjury in the third degree).

I did not authorize any person to use my personal identifying information to open or access any of the accounts or conduct any of the transactions listed in this affidavit. I am willing to cooperate fully with any law enforcement agency, creditor, or credit reporting agency investigating this identity theft.

Signature: ________________________________________

Printed Name: [________________________________]

Date: [__/__/____]

NOTARIZATION BLOCK

STATE OF NEW YORK
COUNTY OF [________________________________]

Before me, the undersigned Notary Public, on this [____] day of [________________________________], 20[____], personally appeared [________________________________], personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.

Notary Public Signature: ________________________________________

Printed Name: [________________________________]

My Commission Expires: [__/__/____]

Registration Number: [________________________________]

Notary Seal/Stamp:

[SEAL]

Note: New York notaries are commissioned by the Secretary of State. Under N.Y. Executive Law § 135-a, a notary must include their registration number. New York does not require a seal/stamp, but it is common practice.

PART C: POLICE REPORT COVER LETTER

[__/__/____]

[________________________________]
[________________________________]
[________________________________]
[________________________________]

Re: Request to File Identity Theft Police Report — N.Y. Penal Law § 190.77 et seq.

Dear Officer/Detective:

I am writing to request that your department accept and file an identity theft report. A sufficiently specific official police report may qualify under 15 U.S.C. § 1681a(q)(4) and 12 C.F.R. § 1022.3(i) for Fair Credit Reporting Act remedies; federal law does not categorically require a police report when the consumer has another qualifying government-agency report.

Background

My personal identifying information has been used without my authorization to open fraudulent accounts, make unauthorized transactions, and/or commit other fraudulent acts as detailed in the attached Identity Theft Affidavit. The total known fraudulent activity amounts to approximately $[________________________________].

New York Criminal Law Provisions

New York has a comprehensive, graduated identity theft criminal statute:

Personal Identifying Information Defined (§ 190.77)

Under New York law, "personal identifying information" includes: name, address, telephone number, date of birth, driver's license number, Social Security number, place of employment, mother's maiden name, financial services account numbers, credit card numbers, ATM numbers, taxpayer ID numbers, computer system passwords, signatures, unique biometric data (fingerprints, voice prints, retinal images), electronic identification numbers, medical information, and health insurance information.

Information and Documents I Am Providing

☐ Completed Identity Theft Affidavit (attached)
☐ FTC Identity Theft Report (attached)
☐ Government-issued photo identification
☐ Proof of current address
☐ Credit reports showing fraudulent accounts (highlighted)
☐ Collection notices for fraudulent debts
☐ Correspondence from creditors
☐ Documentation of financial losses
☐ Other supporting evidence: [________________________________]

Request

I respectfully request that you:

1. Accept this identity theft report and assign a case number
2. Provide me with a copy of the filed police report
3. Investigate the identity theft to the extent possible
4. Refer the matter to appropriate investigative units (NYPD Identity Theft Squad, DA's Office, or state investigators as appropriate)

Respectfully,

Signature: ________________________________________

Printed Name: [________________________________]

Address: [________________________________]

Phone: [________________________________]

Email: [________________________________]

PART D: NEW YORK-SPECIFIC IDENTITY THEFT PROTECTIONS

SHIELD Act (Stop Hacks and Improve Electronic Data Security Act)

The SHIELD Act, effective 2019-2020, significantly strengthened New York's data protection framework:

Expanded Data Breach Notification (GBL § 899-aa):

• Broadened definition of "private information" to include biometric data, username/email with password or security question answers, and account numbers with access codes
• Expanded definition of "breach" to include unauthorized access (not just acquisition)
• Notification must include: contact information, description of breach categories, date or estimate of breach, contact for state and federal agencies providing identity theft information
• Must notify NYS Attorney General, Department of State, and Division of State Police
• For a knowing or reckless violation, the court may impose the greater of $5,000 or up to $20 per failed-notification instance, with the latter amount capped at $250,000

Mandatory Data Security Requirements (GBL § 899-bb):

• A person or business that owns or licenses computerized data containing a New York resident's private information must develop, implement, and maintain reasonable safeguards
• A qualifying small business may tailor its administrative, technical, and physical safeguards to its size and complexity, activities, and the sensitivity of the personal information it collects; the statutory definition separately uses fewer than 50 employees, less than $3 million in gross annual revenue in each of the last three fiscal years, or less than $5 million in year-end total assets
• Civil penalties: up to $5,000 per violation for failure to maintain reasonable safeguards

Identity Theft Services After Breach:

• CRAs that experience breaches involving Social Security numbers must provide 5 years of identity theft prevention and mitigation services to affected consumers

NYS Division of Consumer Protection

Identity Theft Passport Program:

• Provides an official document verifying identity theft victim status
• Can be presented to law enforcement to prevent wrongful arrest
• Contact: (800) 697-1220

Consumer Assistance:

• Files complaints on behalf of consumers with businesses
• Mediates disputes between consumers and businesses
• Website: dos.ny.gov/consumer-protection

NYS Department of Financial Services (DFS)

DFS regulates banking institutions, insurance companies, and financial services companies in New York:

• File complaints regarding financial institutions that fail to respond to identity theft claims
• Contact: (800) 342-3736
• Website: dfs.ny.gov
• DFS cybersecurity regulations (23 NYCRR Part 500) require regulated entities to maintain comprehensive cybersecurity programs

NYS Attorney General

The NYS Attorney General's Office has an Internet Bureau that investigates identity theft:

• File a complaint: ag.ny.gov/complaint-forms
• Phone: (800) 771-7755

Filing Complaints

PART E: SUPPORTING DOCUMENTATION CHECKLIST

Required Documents

☐ Completed Identity Theft Affidavit (Part B of this template)
☐ FTC Identity Theft Report from IdentityTheft.gov
☐ Police report with case number
☐ Government-issued photo identification
☐ Proof of current New York address

New York-Specific Documents

☐ NY Identity Theft Passport (if obtained from Division of Consumer Protection)
☐ SHIELD Act breach notification (if identity theft resulted from data breach)
☐ DFS complaint confirmation (if filed)

Credit-Related Documents

☐ Credit reports from all three CRAs with fraudulent items highlighted
☐ Fraud alert confirmation letters
☐ Security freeze confirmation letters/PINs
☐ Credit monitoring alerts

Fraudulent Account Documents

☐ Statements or notices for fraudulent accounts
☐ Collection letters for fraudulent debts
☐ Correspondence with creditors regarding disputes
☐ Denial letters for credit applications you did not make

Financial Impact Documents

☐ Bank statements showing unauthorized transactions
☐ Records of out-of-pocket expenses
☐ Records of lost wages or time spent resolving identity theft
☐ Documentation of denied credit, employment, or housing

Communication Records

☐ Log of all phone calls (date, time, person spoken to, reference numbers)
☐ Copies of all letters sent (with certified mail receipts)
☐ Email correspondence with creditors, CRAs, and law enforcement

PART F: RECIPIENT LIST — WHO TO SEND THE AFFIDAVIT TO

Use certified mail with return receipt requested for all mailings.

1. Credit Reporting Agencies (All Three)

2. Each Affected Creditor or Financial Institution

3. Debt Collectors

4. NYS Attorney General

5. NYS Division of Consumer Protection (Identity Theft Passport)

6. NYS Department of Financial Services (for financial institution complaints)

7. Internal Revenue Service (If Tax-Related)

IRS identity and tax-return-status verification: 800-908-4490 (identity and tax-return-status verification only; not refund or other tax-account information)

8. Social Security Administration (If SSN Compromised)

Phone: 1-800-772-1213 | Report fraud: oig.ssa.gov

SOURCES AND REFERENCES

• Federal Trade Commission — IdentityTheft.gov: https://www.identitytheft.gov
• Fair Credit Reporting Act, 15 U.S.C. § 1681 et seq.: https://www.law.cornell.edu/uscode/text/15/chapter-41/subchapter-III
• N.Y. Penal Law § 190.77-190.84 (Identity Theft): https://www.nysenate.gov/legislation/laws/PEN/190.77
• N.Y. GBL § 380-s (Security Freeze): https://www.nysenate.gov/legislation/laws/GBS/380-S
• N.Y. GBL § 899-aa (SHIELD Act — Breach Notification): https://ag.ny.gov/resources/organizations/data-breach-reporting/shield-act
• NYS Division of Consumer Protection: https://dos.ny.gov/consumer-protection
• NYS Department of Financial Services: https://www.dfs.ny.gov
• NYS Attorney General — Consumer Protection: https://ag.ny.gov
• Consumer Financial Protection Bureau: https://www.consumerfinance.gov
• Annual Free Credit Reports: https://www.annualcreditreport.com

This template is provided for informational purposes only and does not constitute legal advice. New York identity theft law provides extensive protections through multiple agencies. Consult a qualified attorney licensed in New York for advice specific to your situation.