Identity Theft Affidavit and Police Report Cover - Rhode Island

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — RHODE ISLAND

TABLE OF CONTENTS

1. Affiant Information
2. Identity Theft Affidavit
3. Itemization of Fraudulent Accounts and Activity
4. Statement of Loss
5. Verification and Notarization
6. Police Report Cover Memorandum
7. FCRA § 605B Blocking Demand to Consumer Reporting Agencies
8. Rhode Island Practice Notes
9. Sources and References

1. AFFIANT INFORMATION

2. IDENTITY THEFT AFFIDAVIT

STATE OF RHODE ISLAND

COUNTY OF [PROVIDENCE / KENT / WASHINGTON / NEWPORT / BRISTOL]

I, [AFFIANT NAME], being first duly sworn, depose and say:

1. I am the affiant identified above. I am over the age of eighteen (18), of sound mind, and competent to make this Affidavit. The statements in this Affidavit are based on my personal knowledge.

2. I am the victim of identity theft as that term is defined in 12 C.F.R. § 1022.3(h) and used in R.I. Gen. Laws § 11-49.1-3. A person or persons unknown to me, or whom I identify below, used my "personal identifying information" — as defined in R.I. Gen. Laws § 11-49.1-2, including without limitation my name, Social Security number, date of birth, driver's license or state identification number, alien registration number, government passport number, employer or taxpayer identification number, biometric data, and/or financial-account access devices — without my knowledge, authorization, or consent.

3. I did not authorize the opening of any account, the obtaining of any credit, the cashing of any instrument, the transfer of any property, the filing of any tax return, or any other transaction described in Section 3 below.

4. I have not, in any manner, benefitted from the unauthorized use of my personal identifying information. I have not received any goods, services, money, or credit attributable to the fraudulent transactions, and I have not directly or indirectly aided, abetted, or participated in the conduct of the person who used my identifying information.

5. I first discovered the identity theft on or about [__/__/____] when [BRIEFLY DESCRIBE — e.g., reviewing a credit report, receiving a collection call, opening a 1099, reviewing bank statements].

6. ☐ I do / ☐ I do not know or suspect the identity of the person(s) who used my personal identifying information. [IF KNOWN: NAME, RELATIONSHIP, AND BASIS FOR BELIEF]

7. ☐ I requested a fraud alert and/or security freeze on my consumer reports with the nationwide consumer reporting agencies on [__/__/____]. Record confirmation numbers and review the applicable federal process separately; R.I. Gen. Laws ch. 11-49.3 does not itself establish this consumer request.

8. I executed and submitted (or contemporaneously herewith am submitting) an FTC Identity Theft Report at IdentityTheft.gov, Report Number [NUMBER], dated [__/__/____], which constitutes an "identity theft report" within the meaning of 15 U.S.C. § 1681a(q)(4) and is incorporated herein by reference.

9. I executed (or am contemporaneously executing) a sworn complaint or report with [POLICE DEPARTMENT — e.g., Providence Police Department, Rhode Island State Police] under R.I. Gen. Laws § 11-49.1-3.

10. I make this Affidavit for the purpose of obtaining (a) blocking of the fraudulent information from my consumer reports under 15 U.S.C. § 1681c-2; (b) cessation of collection activity by furnishers and debt collectors; (c) production of documents under 15 U.S.C. § 1681g(e); and (d) such other remedies as are available under federal and Rhode Island law.

3. ITEMIZATION OF FRAUDULENT ACCOUNTS AND ACTIVITY

4. STATEMENT OF LOSS

5. VERIFICATION AND NOTARIZATION

I declare under penalty of perjury under the laws of the United States of America and the State of Rhode Island that the foregoing is true and correct.

Executed this [____] day of [_______________], 20[____], at [CITY], Rhode Island.

[________________________________]

[AFFIANT FULL LEGAL NAME]

STATE OF RHODE ISLAND

COUNTY OF [_____________________]

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

[________________________________]

Notary Public — State of Rhode Island

My commission expires: [__/__/____]

[NOTARY SEAL]

6. POLICE REPORT COVER MEMORANDUM

TO: [POLICE DEPARTMENT]

Attention: Records Bureau / Detective Division

FROM: [AFFIANT NAME], [STREET ADDRESS, CITY, RI ZIP], [PHONE], [EMAIL]

DATE: [__/__/____]

RE: Request to file Identity Theft Report — R.I. Gen. Laws § 11-49.1-3

Dear Officer / Detective:

I am a victim of identity theft as defined in 12 C.F.R. § 1022.3(h) and an offense under R.I. Gen. Laws § 11-49.1-3 (Identity Fraud). I respectfully request that this Department accept and file a written report concerning the fraudulent activity described in the attached materials.

Enclosed:

☐ Sworn Identity Theft Affidavit (notarized)

☐ FTC Identity Theft Report (IdentityTheft.gov), Report No. [____]

☐ Itemization of fraudulent accounts (Section 3)

☐ Supporting documents:

• ☐ Copies of fraudulent statements / collection letters
• ☐ Copies of credit reports highlighting fraudulent tradelines
• ☐ Government-issued photo identification
• ☐ Proof of residence (utility bill / lease)
• ☐ [OTHER]

I am providing this packet pursuant to 15 U.S.C. § 1681a(q)(4), which recognizes a police report as a component of an "identity theft report" required for blocking and dispute remedies. I respectfully request that, upon completion, your Department provide me a copy of the report and the assigned report number for use with consumer reporting agencies, creditors, and the Rhode Island Attorney General's Consumer Protection Unit.

I am willing to assist any investigation, including providing additional documentation, sworn statements, and testimony. I understand that filing a knowingly false report is itself a crime under Rhode Island law.

Respectfully,

[________________________________]

[AFFIANT NAME]

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

[DATE]

[CRA NAME AND ADDRESS]

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

To Whom It May Concern:

I am a victim of identity theft. Pursuant to 15 U.S.C. § 1681c-2, I demand that you block from my consumer file the items of information identified in the attached itemization (Section 3) that resulted from identity theft. Enclosed are:

1. A copy of my FTC Identity Theft Report (Report No. [____]), which constitutes an "identity theft report" under 15 U.S.C. § 1681a(q)(4);
2. A notarized Identity Theft Affidavit;
3. A copy of my police report (Report No. [____]) filed with [POLICE DEPARTMENT];
4. Proof of identity (copy of government-issued ID and a recent utility bill); and
5. The specific identification of the fraudulent items and the basis for asserting that each resulted from identity theft.

You must complete the block no later than four (4) business days after receipt of this notice. 15 U.S.C. § 1681c-2(a). You must also promptly notify the furnisher of the blocked information that the information may be a result of identity theft, that an identity theft report has been filed, that a block has been requested, and the effective dates of the block. § 1681c-2(b).

I additionally request, pursuant to 15 U.S.C. § 1681g(e), that you provide all "business records" relating to each fraudulent transaction — including applications, signature cards, and transaction records — within thirty (30) days.

Please do not require additional documentation beyond what is permitted by 15 U.S.C. § 1681c-2 and 12 C.F.R. § 1022.3(i). If you contend that any item is not properly blocked under § 1681c-2(c), you must provide written notice within five (5) business days specifying the basis for the determination.

Sincerely,

[________________________________]

[AFFIANT NAME]

8. RHODE ISLAND PRACTICE NOTES

• No standalone RI affidavit form. The FTC Identity Theft Affidavit / IdentityTheft.gov report is the de facto standard accepted by Rhode Island law enforcement, the RI Attorney General, and major creditors. This template supplements rather than replaces the FTC submission.
• Criminal predicate. R.I. Gen. Laws § 11-49.1-3 makes identity fraud a crime ranging from misdemeanor to felony depending on loss thresholds. The "personal identifying information" defined in § 11-49.1-2 closely tracks federal scope and includes biometric data, electronic identifiers, and passport numbers.
• Data-breach overlay. R.I. Gen. Laws § 11-49.3-4 governs notice by covered data holders when its breach and significant-identity-theft-risk conditions are met. The covered entity also notifies the Rhode Island Attorney General and major credit reporting agencies when more than 500 residents are to be notified. A victim's affidavit does not itself trigger that entity notice. Reference any received breach notice in Section 3.
• Security freeze and fraud alert. Use the applicable federal consumer-reporting process for these requests. Chapter 11-49.3 addresses data-holder security and breach duties; it does not itself grant an alert or freeze through this affidavit.
• Tax-related identity theft. If a fraudulent state return was filed, also file IRS Form 14039 only if current IRS instructions call for it (federal) and contact the RI Division of Taxation, 1 Capitol Hill, Providence, RI 02908.
• Where to file the police report. RI law does not require filing in any specific municipality. Most victims file with their resident department; a State Police barracks will accept a report where local jurisdiction is unclear.
• AG consumer complaint. The RI Attorney General's Consumer Protection Unit (150 South Main St., Providence; (401) 274-4400; riag.ri.gov) accepts identity theft and data-breach complaints. The AG cannot represent individuals but can investigate and pursue enforcement under the DTPA and ITPA.
• Statute of limitations. R.I. Gen. Laws § 11-49.1-3 sets criminal penalties; civil remedies under DTPA are subject to the catchall 10-year period of R.I. Gen. Laws § 9-1-13(a). Federal FCRA actions (15 U.S.C. § 1681p) must be brought within 2 years of discovery and 5 years from violation.

9. SOURCES AND REFERENCES

• FTC 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
• 15 U.S.C. § 1681c-2 (Block of identity-theft information) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 12 C.F.R. § 1022.3(h)-(i) (identity theft and Identity Theft Report definitions) — https://www.ecfr.gov/current/title-12/chapter-X/part-1022/section-1022.3
• R.I. Gen. Laws Ch. 11-49.1 (Impersonation and Identity Fraud) — https://webserver.rilegislature.gov/Statutes/TITLE11/11-49.1/INDEX.htm
• R.I. Gen. Laws § 11-49.1-2 (Definitions) — https://webserver.rilegislature.gov/Statutes/TITLE11/11-49.1/11-49.1-2.htm
• R.I. Gen. Laws § 11-49.1-3 (Identity fraud) — https://webserver.rilegislature.gov/Statutes/TITLE11/11-49.1/11-49.1-3.htm
• R.I. Gen. Laws Ch. 11-49.3 (Identity Theft Protection Act of 2015) — https://webserver.rilegislature.gov/Statutes/TITLE11/11-49.3/INDEX.htm
• R.I. Gen. Laws § 11-49.3-4 (Notification of breach) — https://webserver.rilegislature.gov/Statutes/TITLE11/11-49.3/11-49.3-4.htm
• Rhode Island Attorney General — Consumer Protection — https://riag.ri.gov/consumerprotection
• Rhode Island State Police — https://risp.ri.gov/

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