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 knowingly making a false written statement under oath is a misdemeanor of the second degree under 18 Pa. C.S. § 4904 (unsworn falsification to authorities) or 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 hereby request, pursuant to standard Pennsylvania law-enforcement practice and to satisfy the Federal Trade Commission's "Identity Theft Report" definition under 15 U.S.C. § 1681a(q)(4), that your agency:

☐ 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 are the product of identity theft. Pursuant to 15 U.S.C. § 1681s-2(a)(6) (FCRA furnisher duties upon notice of identity theft), you must:

1. Cease furnishing information about the disputed account(s) to consumer reporting agencies after receiving this notice;
2. Treat the disputed information as resulting from identity theft and decline to re-furnish it absent independent verification of accuracy;
3. Cease collection of any disputed amount unless and until you can verify the legitimacy of the account;
4. Provide me, free of charge, copies of all application records and transaction records relating to the disputed account(s) under 15 U.S.C. § 1681g(e) within 30 days; and
5. Notify any debt collector to whom you sent the disputed account that the account is the product of identity theft.

Pennsylvania law (FCEUA, 73 P.S. § 2270.4) imposes parallel duties on creditors collecting their own debts. Continued collection of an identity-theft-tainted account is an unfair or deceptive collection practice and a per-se UTPCPL violation under 73 P.S. § 2270.5(a), exposing you to actual damages, treble damages, and attorney's fees under 73 P.S. § 201-9.2.

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 (90 days) at one of the three CRAs (free, propagates to others)

☐ Place extended fraud alert (7 years) once police report is in hand

☐ 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; Strawberry Square, 16th Floor, 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. A person commits identity theft when he/she possesses or uses, through any means, identifying information of another person without consent of that person to further any unlawful purpose. Each act is a separate offense; values may be aggregated across a single scheme for grading purposes (M1 to F1 depending on aggregated value and number of victims). Enhanced penalties apply when the victim is age 60+ or under 18.
• Police-report obligation. While Pennsylvania does not have a single-statute mandate compelling police agencies to take an identity-theft report regardless of jurisdiction, agencies generally do so as a matter of policy because the FCRA Identity Theft Report definition requires it. Reference 18 Pa. C.S. § 4120 in your request, and request a written report bearing a control number.
• 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: Strawberry Square, 16th Floor, 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. 15 U.S.C. § 1681c-1(b) provides one free additional report following an initial fraud alert.
• 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.