Identity Theft Affidavit and Police Report Cover (Oregon)

OREGON IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER

TABLE OF CONTENTS

1. Police Report Cover Letter
2. Identity Theft Affidavit
3. Schedule A — Fraudulent Accounts and Inquiries
4. Schedule B — Documentary Evidence
5. FCRA Block / Dispute Cover Letter
6. Oregon Practice Notes
7. Sources and References

1. POLICE REPORT COVER LETTER

[CONSUMER FULL LEGAL NAME]

[STREET ADDRESS]

[CITY, OR ZIP]

[PHONE] | [EMAIL]

Date: [__/__/____]

[LAW ENFORCEMENT AGENCY — e.g., Portland Police Bureau / Multnomah County Sheriff's Office]

Records / Identity Theft Unit

[STREET ADDRESS]

[CITY, OR ZIP]

Re: Request to File Report of Identity Theft (ORS 165.800 / ORS 165.803)

Dear Records Officer:

I am the victim of identity theft and am requesting that your agency open a case and provide me with a written police report or case number. The conduct constitutes a violation of:

• ORS 165.800 (Identity Theft — Class C felony); and, where applicable,
• ORS 165.803 (Aggravated Identity Theft — Class B felony).

A federal violation of 18 U.S.C. § 1028 may also be present.

I have enclosed:

1. A signed and notarized Identity Theft Affidavit;
2. Schedule A — list of fraudulent accounts and credit-bureau inquiries;
3. Schedule B — supporting documentary evidence (credit reports, statements, correspondence);
4. A copy of my government-issued photo identification; and
5. Proof of my Oregon residency (utility bill / lease).

The discovery date of the theft was [__/__/____], and I estimate the aggregate fraudulent activity at $[________________________________]. [If 10 or more fraudulent transactions / accounts within 180 days, or aggregate loss exceeds $10,000, the conduct may qualify as Aggravated Identity Theft under ORS 165.803.]

Please record this matter as an identity-theft offense and provide a case number, a copy of the report, and the name and contact information of the assigned investigator. A sufficiently specific official Oregon police report may qualify as an "identity theft report" under 15 U.S.C. § 1681a(q)(4) and 12 C.F.R. § 1022.3(i); the report's contents and filing conditions, not its Oregon label alone, control.

Thank you for your prompt attention. Please contact me at the number or email above if you require any additional information.

Respectfully,

[________________________________]

[CONSUMER NAME]

2. IDENTITY THEFT AFFIDAVIT

STATE OF OREGON

COUNTY OF [________________________________]

AFFIDAVIT OF IDENTITY THEFT

I, [CONSUMER FULL LEGAL NAME], being first duly sworn under penalty of perjury under the laws of the State of Oregon and the United States, depose and state as follows:

A. Identification

A.1. My full legal name is [FULL NAME].

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 [ADDRESS], [CITY], Oregon [ZIP], and has been since [__/__/____].

A.5. My government-issued photo identification is an [Oregon Driver License / Oregon ID Card / U.S. Passport] number [________________________________] (copy attached).

B. Discovery of the Identity Theft

B.1. On or about [__/__/____], I discovered that one or more individuals, whose identity is currently [unknown / known to be ____________], had used my personal identifying information without my knowledge, authorization, or consent.

B.2. I learned of the theft through [describe — e.g., notice of new credit account from creditor, denial of credit, IRS notice, debt-collection call, breach notification under ORS 646A.604, credit-monitoring alert].

B.3. I have not authorized any of the accounts, charges, inquiries, or transactions identified in Schedule A attached hereto.

B.4. I am not a relative, roommate, business associate, or current/former domestic partner of any person whom I know or suspect to be the perpetrator. [OR — describe relationship if applicable.]

C. Fraudulent Activity

C.1. The fraudulent accounts, charges, and credit inquiries known to me are itemized in Schedule A.

C.2. I did not apply for, open, authorize, use, or receive proceeds from any account listed in Schedule A.

C.3. I did not authorize anyone else to apply for, open, use, or receive proceeds from any account listed in Schedule A.

C.4. The aggregate fraudulent loss known to me to date is $[________________________________].

D. Reports Filed

D.1. ☐ I have filed a report with the [LAW ENFORCEMENT AGENCY] on [__/__/____], Case No. [________________________________].

D.2. ☐ I have filed an FTC Identity Theft Report at IdentityTheft.gov on [__/__/____], Report No. [________________________________].

D.3. ☐ I have placed a fraud alert with [Equifax / Experian / TransUnion] on [__/__/____].

D.4. ☐ I have placed a security freeze with each of the three nationwide consumer reporting agencies on [__/__/____].

D.5. ☐ I have notified the Social Security Administration / U.S. Postal Inspection Service / Internal Revenue Service (IRS Form 14039 only if current IRS instructions call for it) on [__/__/____].

E. Cooperation

E.1. I am willing to assist law enforcement and any creditor, financial institution, or consumer reporting agency in the prosecution and investigation of this identity theft.

E.2. I will appear and testify if necessary.

E.3. I have not received and will not knowingly receive any benefit from any transaction listed in Schedule A.

F. Demand

F.1. I demand that all consumer reporting agencies block the fraudulent information identified in Schedule A pursuant to 15 U.S.C. § 1681c-2.

F.2. I demand that all furnishers of fraudulent information cease reporting and furnishing it pursuant to 15 U.S.C. § 1681s-2(a)(6).

F.3. I demand that any creditor or debt collector immediately close the fraudulent account, cease collection activity, and confirm zero liability in writing.

G. Verification

I have read this affidavit and the attached Schedules A and B; the contents are true and correct of my own knowledge except as to those matters stated upon information and belief, and as to those matters I believe them to be true. I understand that any false statement made herein is punishable as a Class C felony under ORS 162.065 (perjury) and may also constitute a violation of 18 U.S.C. § 1001.

[________________________________]

[CONSUMER NAME]

Date: [__/__/____]

NOTARY ACKNOWLEDGMENT

State of Oregon, County of [________________________________]

Subscribed and sworn to (or affirmed) before me on this [____] day of [_______________], 20[____], by [CONSUMER NAME], who is personally known to me or who has produced [type of identification] as identification.

[________________________________]

Notary Public — State of Oregon

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

3. SCHEDULE A — FRAUDULENT ACCOUNTS AND INQUIRIES

4. SCHEDULE B — DOCUMENTARY EVIDENCE

☐ Tri-merge or single-bureau credit reports (Experian, Equifax, TransUnion)

☐ Statements showing fraudulent charges

☐ Correspondence from creditors or collectors

☐ Data-breach notifications received under ORS 646A.604

☐ Government-issued photo identification (front and back)

☐ Proof of Oregon residency (utility bill, lease, voter registration)

☐ FTC Identity Theft Report (IdentityTheft.gov)

☐ Police report or case-number confirmation

☐ Postal Inspection Service / SSA confirmations and IRS confirmation, including
IRS Form 14039
only if the current IRS instructions called for it

5. FCRA BLOCK / DISPUTE COVER LETTER

[CONSUMER NAME]

[ADDRESS]

[CITY, OR ZIP]

Date: [__/__/____]

[Equifax — P.O. Box 105069, Atlanta, GA 30348-5069]

[Experian — P.O. Box 9554, Allen, TX 75013]

[TransUnion — P.O. Box 2000, Chester, PA 19016]

Re: Request to Block Information Resulting from Identity Theft — 15 U.S.C. § 1681c-2

Dear Sir or Madam:

I am a victim of identity theft. Pursuant to 15 U.S.C. § 1681c-2, I request that you block from my consumer file the information identified in Schedule A of the enclosed Identity Theft Affidavit. The information does not relate to any transaction by me.

Enclosed are:

• My signed and notarized Identity Theft Affidavit;
• Schedule A — itemized list of fraudulent tradelines and inquiries;
• Schedule B — supporting documentation;
• A copy of my Oregon-issued photo identification;
• Proof of my current address; and
• [Police report case number / FTC Identity Theft Report number].

Please block the listed items within four (4) business days as required by 15 U.S.C. § 1681c-2(a) and notify each furnisher under § 1681c-2(b). Please also place an extended fraud alert on my file pursuant to 15 U.S.C. § 1681c-1(b) for seven (7) years.

If you decline to block any item, please cite the specific statutory exception in 15 U.S.C. § 1681c-2(c) on which you rely and provide a written explanation.

Sincerely,

[________________________________]

[CONSUMER NAME]

6. OREGON PRACTICE NOTES

• ORS 165.800 vs. ORS 165.803. Standard identity theft is a Class C felony. The "aggravated" tier (Class B felony) applies when there are 10+ separate incidents within 180 days, aggregate loss is $10,000+, or the perpetrator possesses 10+ pieces of personal identification belonging to 10+ different persons. Flag aggravated facts in the police-report cover letter so the agency charges appropriately.
• Oregon Consumer Information Protection Act (OCIPA), ORS 646A.600–.628. OCIPA governs business-side duties: implementing safeguards (ORS 646A.622), notifying Oregon residents within 45 days of a breach (ORS 646A.604), and prohibiting public posting/printing of SSNs (ORS 646A.620). DCBS enforces; civil penalties up to $1,000/violation, capped at $500,000.
• Free security freeze. ORS 646A.604/646A.628 entitle Oregon consumers to free placement, lift, and removal of security freezes at the three nationwide CRAs and at specialty agencies (ChexSystems, NCTUE, LexisNexis, Innovis).
• FTC Identity Theft Report. An FTC Identity Theft Report created through IdentityTheft.gov may qualify under 15 U.S.C. § 1681a(q)(4) and 12 C.F.R. § 1022.3(i); this private affidavit can supply supporting detail but is not a categorically required second report. Submit the qualifying report with the other materials required by 15 U.S.C. § 1681c-2 to request the four-business-day block.
• Civil leverage. A debt collector who continues to pursue a debt that the affidavit shows is fraudulent risks liability under FDCPA § 1692e/§ 1692f and Oregon UDCPA, ORS 646.639/646.641. The affidavit functions both as consumer remedy and as plaintiff's evidence in any later civil action.

• Tax-related theft. Follow the current IRS guide and file
  IRS Form 14039
  only if its instructions call for it. Consider the separate IRS Identity
  Protection PIN and Oregon Department of Revenue routes.

• Mail theft. If mail theft is suspected, file a report with the U.S. Postal Inspection Service (1-877-876-2455).

• Notary. Oregon authorizes remote online notarization under ORS 194.215; ensure the notarial certificate states the technology used.
• Statute of limitations on civil claims. Oregon's general 2-year SOL for personal-injury torts (ORS 12.110) and 6-year SOL for actions on a contract or statutory liability (ORS 12.080) may apply depending on the theory of recovery. Diary the SOL from the date of discovery.

7. SOURCES AND REFERENCES

• ORS 165.800 — https://oregon.public.law/statutes/ors_165.800
• ORS 165.803 — https://oregon.public.law/statutes/ors_165.803
• ORS 646A.600 et seq. — https://oregon.public.law/statutes/ors_646a.600
• Oregon DOJ Consumer Protection — Identity Theft & Data Breaches — https://www.doj.state.or.us/consumer-protection/id-theft-data-breaches/
• 15 U.S.C. § 1681c-2 (FCRA block) — https://www.govinfo.gov/app/details/USCODE-2023-title15/USCODE-2023-title15-chap41-subchapIII-sec1681c-2
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• FTC Identity Theft Resource — https://www.consumer.ftc.gov/topics/identity-theft
• IRS Form 14039 only if current IRS instructions call for it (Identity Theft Affidavit) — https://www.irs.gov/identity-theft-fraud-scams/identity-theft-guide-for-individuals#form14039
• U.S. Postal Inspection Service — https://www.uspis.gov/

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