Identity Theft Affidavit and Police Report Cover - Pennsylvania - Preparation Worksheet

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER PACKET — PENNSYLVANIA

TABLE OF CONTENTS

1. Cover Letter to Law Enforcement
2. Victim Information
3. Affidavit of Identity Theft (Notarized)
4. Schedule of Fraudulent Accounts and Transactions
5. Documents Attached / Enclosed
6. Demand for Police Report
7. FCRA § 605B Blocking Demand to Consumer Reporting Agencies
8. Notice to Creditors and Furnishers
9. Pennsylvania BPINA Demand (If Breach-Related)
10. Recovery Action Checklist
11. Pennsylvania Practice Notes
12. Sources and References

1. COVER LETTER TO LAW ENFORCEMENT

Date: [__/__/____]

To: [POLICE DEPARTMENT / SHERIFF'S OFFICE / PENNSYLVANIA STATE POLICE TROOP ___]

Address: [STREET ADDRESS, CITY, PA ZIP]

Re: Report of Identity Theft Pursuant to 18 Pa. C.S. § 4120

Dear Officer / Records Custodian:

I, [VICTIM FULL LEGAL NAME], am the victim of identity theft as defined by 18 Pa. C.S. § 4120. I hereby request that your agency take a written police report of this offense and provide me a copy bearing an official report number.

Enclosed is my notarized Affidavit of Identity Theft, supporting documentation, and a Schedule of Fraudulent Accounts and Transactions. I respectfully request:

☐ A police-report case number;

☐ A certified copy of the report for use with creditors and consumer reporting agencies;

☐ Referral, if appropriate, to the Pennsylvania Office of Attorney General for prosecution under 18 Pa. C.S. § 4120, and to federal authorities for prosecution under 18 U.S.C. § 1028 and § 1028A; and

☐ Coordination, if appropriate, with the FBI's Internet Crime Complaint Center (IC3) and the U.S. Postal Inspection Service.

I am cooperating fully and will make myself available for further interviews.

Sincerely,

[________________________________]

[VICTIM NAME]

2. VICTIM INFORMATION

3. AFFIDAVIT OF IDENTITY THEFT (NOTARIZED)

COMMONWEALTH OF PENNSYLVANIA

COUNTY OF [COUNTY]

I, [VICTIM FULL LEGAL NAME], being duly sworn according to law, depose and state:

3.1. I am the victim of identity theft as defined by 18 Pa. C.S. § 4120 and 18 U.S.C. § 1028. I am a resident of [COUNTY] County, Pennsylvania.

3.2. I did not authorize, consent to, or benefit from the transactions, accounts, or activities listed on the attached Schedule of Fraudulent Accounts and Transactions.

3.3. I did not provide my identifying information (including name, Social Security number, date of birth, driver's license, financial account numbers, or electronic credentials) to the person(s) who used it without authorization, except to the extent it was lawfully held by [describe entities, e.g., my employer, my bank].

3.4. I have no business or personal relationship with the merchants, lenders, or service providers that opened or maintain the fraudulent accounts, except as expressly noted on the Schedule.

3.5. I did not authorize anyone else to use my identity for any purpose, lawful or unlawful, on the dates and in the manner alleged.

3.6. I am providing this affidavit (i) to support a police report under 18 Pa. C.S. § 4120, (ii) to support FCRA Identity Theft Report status under 15 U.S.C. § 1681a(q)(4), (iii) to invoke FCRA § 605B blocking under 15 U.S.C. § 1681c-2, (iv) to demand fraud alerts and security freezes under 15 U.S.C. § 1681c-1, and (v) to demand that creditors and furnishers correct or remove fraudulent tradelines.

3.7. I understand that a knowingly false statement under oath may be punishable as false swearing under 18 Pa.C.S. § 4903 or, if made in an official proceeding and material, as perjury under 18 Pa.C.S. § 4902.

[________________________________]

[VICTIM NAME]

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

[________________________________]

Notary Public

(My Commission Expires: [_______________])

4. SCHEDULE OF FRAUDULENT ACCOUNTS AND TRANSACTIONS

Total alleged fraudulent loss: $[____________]

5. DOCUMENTS ATTACHED / ENCLOSED

☐ Government-issued photo ID (driver's license / Pennsylvania ID / passport)

☐ Proof of current address (utility bill / lease)

☐ FTC IdentityTheft.gov report (printable Identity Theft Report)

☐ Copies of credit reports (Equifax / Experian / TransUnion) with fraudulent items circled

☐ Copies of fraudulent account statements, bills, or notices

☐ Correspondence with creditors, banks, or CRAs

☐ Police report (if previously filed) — Report No. [________________]

☐ Pennsylvania Office of Attorney General — Identity Theft Resource Materials

☐ [Other: ________________________________]

6. DEMAND FOR POLICE REPORT

To Law Enforcement:

I request a police report to document this matter and support an investigation. A separate FTC Identity Theft Report may also qualify for federal credit-reporting remedies. Please:

☐ Take a written police report of this identity-theft offense;

☐ Provide me a copy of that report bearing an official report number;

☐ Forward a copy to the appropriate prosecutorial authority (District Attorney; Pennsylvania Office of Attorney General); and

☐ Note in the report that the offense is alleged under 18 Pa. C.S. § 4120 (identity theft).

A sufficiently specific official police report may constitute an "Identity Theft Report" under 15 U.S.C. § 1681a(q)(4) and 12 C.F.R. § 1022.3(i). An FTC Identity Theft Report created through IdentityTheft.gov is an alternative qualifying report; my notarized affidavit and government-issued ID provide supporting documentation for the requested relief.

7. FCRA § 605B BLOCKING DEMAND TO CONSUMER REPORTING AGENCIES

To the Recipient Consumer Reporting Agency:

Pursuant to 15 U.S.C. § 1681c-2 (FCRA § 605B), I demand that you block the reporting of the information listed on the attached Schedule because such information resulted from identity theft. Within four (4) business days of receipt of this packet, you must:

1. Block the disputed information from appearing in any consumer report;
2. Notify the furnisher that the information may be a result of identity theft;
3. Notify me of the block; and
4. Decline to reinsert the information except as expressly permitted by 15 U.S.C. § 1681c-2(c).

Enclosed proof of identity and identity-theft-report documentation:

☐ Copy of government-issued photo ID;

☐ Copy of proof of address;

☐ Police report bearing official report number; and

☐ Notarized affidavit of identity theft (Section 3 above).

I also request, pursuant to 15 U.S.C. § 1681c-1, an extended fraud alert for seven (7) years on my consumer file at all three nationwide CRAs.

I separately request a security freeze under 15 U.S.C. § 1681c-1(i) at no charge.

8. NOTICE TO CREDITORS AND FURNISHERS

To Each Creditor / Furnisher:

You are notified that the account(s) listed on the Schedule resulted from identity theft. I enclose my identity theft report and ask you to review the account and confirm its status in writing.

If you furnish information about these accounts to a consumer reporting agency, I submit this identity theft report to your designated address under 15 U.S.C. § 1681s-2(a)(6)(B). Please stop furnishing the identified information unless you subsequently know, or I inform you, that it is correct. If a consumer reporting agency sends you a block notice under § 1681c-2, use the reasonable procedures required by § 1681s-2(a)(6)(A) to prevent refurnishing the blocked information.

I also request copies of application and business transaction records within your control that relate to the alleged identity theft under 15 U.S.C. § 1681g(e), subject to the identity and claim verification required by that section. Please identify any debt collector handling this account so I may notify that collector directly. If a debt collector acting for a third party receives notice that the debt information may be fraudulent or the result of identity theft, 15 U.S.C. § 1681m(g) requires that collector to notify the third party.

9. PENNSYLVANIA BPINA DEMAND (IF BREACH-RELATED)

To [BREACHED ENTITY]:

You are placed on notice that I am a Pennsylvania resident whose personal information has been compromised. Pursuant to the Pennsylvania Breach of Personal Information Notification Act, 73 P.S. §§ 2301-2329 (as amended by Act 33 of 2024, effective Sept. 26, 2024), I demand:

1. Confirmation, in writing, of whether your entity has experienced a security breach affecting my personal information as defined by 73 P.S. § 2302;
2. Statutory notice under 73 P.S. § 2303 if such a breach has occurred;
3. If notification to consumer reporting agencies is required and the data conditions in 73 P.S. § 2305.4(b) are met, the qualifying credit report and twelve (12) months of no-cost credit monitoring required by Act 33 of 2024;
4. Concurrent notification to the Office of the Pennsylvania Attorney General if statutory notice must be given to more than 500 affected Pennsylvania individuals (73 P.S. § 2303(c.1)); and
5. Preservation of all records relating to the breach.

A BPINA violation is deemed an unfair or deceptive act or practice under 73 P.S. § 2308, but that section gives the Pennsylvania Office of Attorney General exclusive authority to bring the UTPCPL action for the BPINA violation.

10. RECOVERY ACTION CHECKLIST

☐ File FTC Identity Theft Report at IdentityTheft.gov

☐ File local police report under 18 Pa. C.S. § 4120

☐ Place initial fraud alert (at least one year unless you request earlier removal) at one of the three CRAs (free, propagates to others)

☐ Place extended fraud alert (7 years) after obtaining a qualifying Identity Theft Report and providing proof of identity

☐ Place security freeze at all three CRAs (free under 15 U.S.C. § 1681c-1(i))

☐ Send § 605B blocking demands to all three CRAs (Section 7)

☐ Send furnisher notices to each creditor (Section 8)

☐ Request free credit reports under 15 U.S.C. § 1681j(d) (free additional reports for ID-theft victims)

☐ Notify banks and replace compromised accounts / debit and credit cards

☐ Replace driver's license through PennDOT (Form DL-80) if compromised

☐ Apply for new SSN through SSA only as last resort

☐ Notify IRS using IRS Form 14039 only if current IRS instructions call for it

☐ Notify Pennsylvania Office of Attorney General Bureau of Consumer Protection: (800) 441-2555; 15th Floor, Strawberry Square, Harrisburg, PA 17120

☐ Calendar 30-day, 60-day, and 90-day follow-up dates

☐ Retain all certified-mail receipts and tracking records

11. PENNSYLVANIA PRACTICE NOTES

• 18 Pa. C.S. § 4120 elements and grading. Identity theft requires possession or use of another person's identifying information without consent to further an unlawful purpose. Values in one scheme may be aggregated across victims. The base grade is M1 below $2,000, F3 at $2,000 or more or for conspiracy, and F2 for a third or later offense. The grade rises one level when the victim is age 60 or older, care-dependent, or under 18.
• Police-report request. Ask the appropriate agency to document the alleged offense under 18 Pa. C.S. § 4120 and provide a case number. Federal FCRA relief calls for a qualifying Identity Theft Report, which may be an FTC report; it does not categorically require a separate police report.
• Pennsylvania Office of Attorney General Identity Theft Resources. The PA AG Bureau of Consumer Protection maintains identity-theft assistance materials and may refer cases for criminal prosecution. Contact: 15th Floor, Strawberry Square, Harrisburg, PA 17120; (800) 441-2555; attorneygeneral.gov.
• BPINA amendments (Act 33 of 2024). Amendments effective September 26, 2024 revised the personal-information definition, added concurrent Attorney General notice when more than 500 Pennsylvania individuals must be notified, reduced the consumer-reporting-agency threshold to more than 500 notices at one time, and added conditional credit-report and 12-month monitoring duties. Medical information is included in the statutory definition only when it is in the possession of a State agency or State agency contractor; health-insurance information is separately listed.
• FCRA § 605B blocking. A CRA must block disputed information within 4 business days of receiving (i) proof of consumer's identity, (ii) a copy of an Identity Theft Report, (iii) consumer identification of the information to be blocked, and (iv) the consumer's statement that the information does not relate to a transaction by the consumer. 15 U.S.C. § 1681c-2.
• No private BPINA enforcement action stated in the Act. Section 2308 gives the Office of Attorney General exclusive authority to bring a UTPCPL action for a BPINA violation. Any separate FCRA, FCEUA, contract, tort, or other claim requires its own elements and authority.
• Free credit reports for victims. 15 U.S.C. § 1681j(d) provides free credit reports beyond the ordinary annual report when identity theft is suspected. After an initial fraud alert, § 1681c-1(a)(2) allows one free file disclosure; after an extended fraud alert, § 1681c-1(b)(2) allows two free file disclosures within 12 months.
• Statute of limitations on civil claims. FCRA: 2 years from discovery, max 5 years from violation (15 U.S.C. § 1681p). UTPCPL: 6 years (42 Pa. C.S. § 5527). Common-law negligence: 2 years (42 Pa. C.S. § 5524).
• Memorialize all communications. Send by Certified Mail, Return Receipt Requested. Retain all tracking, certified-mail green cards, and CRA dispute confirmations. These documents prove notice for FCRA willfulness claims (15 U.S.C. § 1681n).

12. SOURCES AND REFERENCES

• 18 Pa. C.S. § 4120 (identity theft) — https://www.legis.state.pa.us/cfdocs/legis/LI/consCheck.cfm?txtType=HTM&ttl=18&div=0&chpt=41&sctn=20&subsctn=0
• Pennsylvania Breach of Personal Information Notification Act, 73 P.S. §§ 2301-2329 — https://www.legis.state.pa.us/WU01/LI/LI/US/HTM/2005/0/0094..HTM
• Pennsylvania Office of Attorney General — BPINA — https://www.attorneygeneral.gov/bpina/
• Pennsylvania Unfair Trade Practices and Consumer Protection Law, 73 P.S. §§ 201-1 et seq. — https://www.legis.state.pa.us/cfdocs/legis/LI/uconsCheck.cfm?txtType=HTM&yr=1968&sessInd=0&smthLwInd=0&act=387
• Fair Credit Reporting Act, 15 U.S.C. §§ 1681 et seq. — https://www.law.cornell.edu/uscode/text/15/chapter-41/subchapter-III
• 15 U.S.C. § 1681c-2 (information block) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 15 U.S.C. § 1681c-1 (fraud alerts and security freezes) — https://www.law.cornell.edu/uscode/text/15/1681c-1
• 15 U.S.C. § 1681s-2 (furnisher responsibilities) — https://www.law.cornell.edu/uscode/text/15/1681s-2
• 18 U.S.C. § 1028 (federal identity theft) — https://www.law.cornell.edu/uscode/text/18/1028
• 18 U.S.C. § 1028A (aggravated identity theft) — https://www.law.cornell.edu/uscode/text/18/1028A
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• IRS Identity Theft Affidavit (IRS Form 14039 only if current IRS instructions call for it) — https://www.irs.gov/identity-theft-fraud-scams/identity-theft-guide-for-individuals#form14039
• Pennsylvania Attorney General Bureau of Consumer Protection — https://www.attorneygeneral.gov/public-protection-division/bureau-consumer-protection/
• Equifax — https://www.equifax.com/personal/credit-report-services/credit-fraud-alerts/
• Experian — https://www.experian.com/fraud/center.html
• TransUnion — https://www.transunion.com/fraud-victim-resource/place-fraud-alert

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