Identity Theft Affidavit and Police Report Cover - Utah

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — UTAH

TABLE OF CONTENTS

1. Part A — Police Report Cover Letter
2. Part B — Sworn Identity Theft Affidavit
3. Part C — Notification Letters to Consumer-Reporting Agencies
4. Part D — Notification Letters to Furnishers
5. Utah Practice Notes
6. Sources and References

1. PART A — POLICE REPORT COVER LETTER

[VICTIM NAME]

[STREET ADDRESS]

[CITY, UTAH ZIP]

[TELEPHONE] [EMAIL]

Date: [__/__/____]

[LAW-ENFORCEMENT AGENCY — e.g., Salt Lake City Police Department, [_____] County Sheriff's Office]

Records / Identity Theft Unit

[STREET ADDRESS]

[CITY, UTAH ZIP]

Re: Request to File Identity Theft Report — Utah Victim

Dear Records Officer:

I am a Utah resident and the victim of identity theft. I am requesting that your agency take and provide me with a written police report documenting the criminal acts described in the attached sworn affidavit, pursuant to the federal Fair Credit Reporting Act, 15 U.S.C. § 1681a(q), and the Utah identity-fraud statute, Utah Code § 76-6-1102.

The attached affidavit describes:

• ☐ The unauthorized use of my personal identifying information;
• ☐ The unauthorized use of my financial transaction devices or account access devices;
• ☐ The opening of fraudulent credit accounts in my name;
• ☐ Existing-account takeover or unauthorized transactions;
• ☐ Government-document or benefit fraud;
• ☐ Tax-return identity theft;
• ☐ Medical identity theft;
• ☐ Synthetic identity fraud combining my SSN with another person's identifiers;
• ☐ Other: [_______________________________].

Conduct of this nature is criminal under Utah Code § 76-6-1102 (identity fraud crime), with penalties graded under Utah Code § 76-6-1103: a class A misdemeanor where the value is less than $500; a third-degree felony where the value is $500 to $4,999; and a second-degree felony where the value equals or exceeds $5,000. Related conduct may also implicate Utah Code §§ 76-6-506 (financial transaction card offenses), 76-6-1104 (mail theft), and 76-10-1801 (communications fraud).

I request that the report be assigned a case number and that I be provided with:

1. The case number;
2. A certified copy of the report; and
3. The name and contact information of the assigned investigator.

I have also filed (or will file) a Federal Trade Commission Identity Theft Report at IdentityTheft.gov (FTC report number: [_______________]) and a Utah identity-theft report through the Utah Attorney General's Identity Theft Reporting Information System ("IRIS") at idtheft.utah.gov (IRIS number: [_______________]), copies of which are enclosed. Together with this police report, I will submit the package to the consumer-reporting agencies under 15 U.S.C. § 1681c-2 to obtain an information block.

Thank you for your assistance.

Sincerely,

[________________________________]

[VICTIM NAME]

Enclosures: Sworn Identity Theft Affidavit; FTC Identity Theft Report; Utah IRIS Report (if filed); copies of supporting documentation (account statements, fraudulent applications, correspondence).

2. PART B — SWORN IDENTITY THEFT AFFIDAVIT

STATE OF UTAH

COUNTY OF [_______________]

I, [VICTIM FULL LEGAL NAME], being first duly sworn upon oath, depose and state as follows:

A. Identification of Affiant

1. My full legal name is [_______________________________].

2. My date of birth is [__/__/____].

3. My residential address is [_______________________________], [CITY], Utah [ZIP].

4. The last four digits of my Social Security number are [XXX-XX-_____].

5. My Utah driver's license / ID number is [_______________] (issued [__/__/____]).

B. Statement of Identity Theft

6. I am the victim of identity theft. I did not authorize, consent to, or benefit from the transactions, accounts, or activity described below. I had no relationship with any of the persons or entities that committed the fraudulent acts.

7. I first discovered the identity theft on or about [__/__/____] when [DESCRIBE — e.g., I received a credit-card statement for an account I never opened; I was denied credit and pulled my credit report; I received an IRS notice; I received a debt-collection call; I received a Utah Code § 13-44-202 breach notice from [COMPANY]].

8. To the best of my knowledge, the identity thief obtained my personal identifying information by [DESCRIBE — e.g., a data breach at [COMPANY]; a stolen wallet on [__/__/____]; phishing email; lost or stolen mail; unknown means].

C. Fraudulent Accounts and Transactions

9. The following accounts, transactions, or items are fraudulent and were not authorized by me:

10. I have circled and identified these items on the credit reports attached to this affidavit (Equifax, Experian, and TransUnion).

D. Police Report and Government Filings

11. I have filed or am concurrently filing a police report with [LAW-ENFORCEMENT AGENCY] in [CITY/COUNTY], Utah.

12. The case number assigned is [_______________] (if known; otherwise, "to be assigned").

13. I have filed or am concurrently filing a Federal Trade Commission Identity Theft Report at IdentityTheft.gov, FTC report number [_______________].

14. I have filed or am concurrently filing a Utah identity-theft report through the Utah Attorney General's Identity Theft Reporting Information System (IRIS), report number [_______________].

E. No Authorization or Benefit

15. I did not provide my information to the perpetrator and did not authorize anyone to use my information.

16. I did not receive any goods, services, money, or other benefit from the fraudulent accounts or transactions.

17. I am not making this statement for any purpose unrelated to the identity theft.

F. Request for FCRA Block and Furnisher Action

18. Pursuant to 15 U.S.C. § 1681c-2, I request that each consumer-reporting agency receiving this affidavit block the fraudulent information identified in Section C from my credit file within four (4) business days of receipt.

19. Pursuant to 15 U.S.C. § 1681s-2(a)(6) and (b) and 15 U.S.C. § 1681g(e), I request that each furnisher receiving this affidavit:

• Cease reporting the fraudulent information to all consumer-reporting agencies;
• Provide me with all application records, transaction records, and account documentation related to the fraudulent account(s) within 30 days; and
• Refrain from selling, transferring, or placing for collection any debt arising from the fraudulent account(s).

20. I additionally invoke my right under Utah Code § 13-45-201 to place a security freeze on my consumer-reporting agency files at no charge.

G. Penalty of Perjury

21. I declare under penalty of perjury under the laws of the State of Utah and the United States that the foregoing is true and correct to the best of my knowledge and belief. Utah Code § 78B-5-705.

Executed on [__/__/____] at [CITY], Utah.

[________________________________]

[VICTIM NAME] (Affiant)

ACKNOWLEDGMENT

State of Utah, County of [_______________]

Subscribed and sworn to (or affirmed) before me this [____] day of [_______________], 20[____], by [VICTIM NAME], who proved to me on the basis of satisfactory evidence to be the person who appeared before me.

[________________________________]

Notary Public

My Commission Expires: [_______________]

(Notary Seal)

3. PART C — NOTIFICATION LETTERS TO CONSUMER-REPORTING AGENCIES

[VICTIM NAME]

[ADDRESS]

Date: [__/__/____]

VIA U.S.P.S. CERTIFIED MAIL — RETURN RECEIPT REQUESTED

[Equifax Information Services LLC, P.O. Box 105069, Atlanta, GA 30348-5069]

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

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

Re: Identity Theft — Request for Block under 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 request that you block the fraudulent items identified on the enclosed credit report (circled) within four (4) business days of your receipt of this request.

I enclose the following:

• ☐ Sworn Identity Theft Affidavit (notarized);
• ☐ Police report from [AGENCY], case number [_______________];
• ☐ FTC Identity Theft Report from IdentityTheft.gov, report number [_______________];
• ☐ Utah IRIS report number [_______________] (if applicable);
• ☐ Copy of my Utah driver's license / ID;
• ☐ Proof of current address (utility bill);
• ☐ A copy of my credit report with fraudulent items circled.

In addition, please:

1. Place an extended fraud alert on my file pursuant to 15 U.S.C. § 1681c-1(b) for seven (7) years;
2. Place a security freeze on my file pursuant to Utah Code § 13-45-201, effective immediately and at no charge;
3. Provide me with two free credit reports during the next twelve months;
4. Suppress my name from prescreened-offer lists for five (5) years per 15 U.S.C. § 1681b(e); and
5. Provide written confirmation of all actions taken.

Sincerely,

[________________________________]

[VICTIM NAME]

4. PART D — NOTIFICATION LETTERS TO FURNISHERS

[VICTIM NAME]

[ADDRESS]

Date: [__/__/____]

VIA U.S.P.S. CERTIFIED MAIL — RETURN RECEIPT REQUESTED

[FURNISHER NAME — Fraud Department / Registered Agent]

[ADDRESS]

Re: Fraudulent Account / Reference No.: [_______________]

Identity Theft Notice and Demand under 15 U.S.C. §§ 1681s-2 and 1681g(e)

To the Fraud Department:

I am a victim of identity theft. The account referenced above was opened or used without my authorization. Pursuant to the federal Fair Credit Reporting Act and the Utah Consumer Sales Practices Act, I demand the following:

1. Cease furnishing. Do not furnish any information regarding this account to any consumer-reporting agency. 15 U.S.C. § 1681s-2(a)(6).

2. Investigate and correct. Conduct a reasonable investigation and correct or delete the fraudulent information. 15 U.S.C. § 1681s-2(b).

3. Provide records. Provide me, within 30 days, with copies of all application records, transaction records, signature cards, IP logs, device fingerprints, and other documentation relating to this fraudulent account, pursuant to 15 U.S.C. § 1681g(e).

4. No collection or sale. Do not place this account for collection, sell or transfer it, or sue on it. To do so on a debt known to arise from identity theft would constitute a deceptive or unconscionable act under Utah Code §§ 13-11-4 and 13-11-5 and an unfair practice under 15 U.S.C. § 1692f.

5. Breach disclosure. If this fraud is connected to any breach of system security previously discovered by you, please provide the notice required under Utah Code § 13-44-202, including the categories of personal information compromised and the date(s) of breach.

Enclosures: Sworn Identity Theft Affidavit; police report; FTC Identity Theft Report; Utah IRIS report (if applicable); copy of Utah ID.

Sincerely,

[________________________________]

[VICTIM NAME]

5. UTAH PRACTICE NOTES

• Utah identity-fraud statute. Utah Code § 76-6-1102 prohibits the knowing or intentional use, with fraudulent intent, of another's personal identifying information to obtain credit, goods, services, employment, medical information, or any other thing of value. The statute defines "personal identifying information" broadly to include name, date of birth, address, telephone number, driver's license or state-ID number, Social Security number, employee ID numbers, mother's maiden name, electronic identification numbers, electronic signatures (Title 46, Ch. 4), and any other numbers that can be used to access financial resources or medical information. Penalties under Utah Code § 76-6-1103 grade with the value involved (class A misdemeanor under $500; third-degree felony $500–$4,999; second-degree felony $5,000+).
• Utah Identity Theft Protection Act (Protection of Personal Information Act). Utah Code § 13-44-101 et seq. requires any person who owns or licenses computerized personal information about a Utah resident to investigate any breach of system security in good faith and to provide notice "in the most expedient time possible without unreasonable delay" if misuse for identity theft or fraud has occurred or is reasonably likely. Notice may be by mail, email (if the customary medium), telephone, or substitute notice. Where 500+ Utah residents are affected, notice must also be given to the Utah Attorney General and Utah Cyber Center; where 1,000+ are affected, to the nationwide CRAs. Waiver is void as against public policy.
• Utah security freeze. Utah Code § 13-45-201 et seq. authorizes a Utah consumer to place a security freeze on the consumer's file at each nationwide CRA at no charge. Use the freeze in addition to a fraud alert.
• Utah IRIS (idtheft.utah.gov). The Utah Attorney General's Identity Theft Reporting Information System provides a centralized intake for victims and a state-issued report number that local law enforcement and creditors will recognize. Filing IRIS is free and complementary to the FTC report.
• Police duty to take report. Utah law-enforcement agencies will accept identity-theft reports from any victim. If the local agency declines, contact the Utah Attorney General's office (https://attorneygeneral.utah.gov) or the Utah Bureau of Investigation.
• FCRA blocking timeline. Under 15 U.S.C. § 1681c-2(a), CRAs must block within 4 business days of a complete request. The CRA may decline only on narrow grounds (15 U.S.C. § 1681c-2(c)) — material misrepresentation, blocking already obtained for the same item, or use of the block for fraudulent purposes.
• Free credit reports. Identity-theft victims are entitled to free credit reports beyond the standard annual entitlement. Use https://www.annualcreditreport.com.
• Tax identity theft. If the affidavit covers IRS issues, also file IRS Form 14039 (Identity Theft Affidavit) and call the IRS Identity Protection Specialized Unit at (800) 908-4490. For Utah state tax fraud, contact the Utah State Tax Commission's Identity Theft Unit.
• Medical identity theft. HIPAA covered entities must provide an accounting of disclosures under 45 C.F.R. § 164.528. Send a written request.
• Restitution in criminal case. Utah Code § 77-38b-205 (Crime Victims Restitution Act) authorizes restitution to victims of identity-fraud crimes. Provide the prosecutor with a documented loss claim.
• Civil action. In addition to FCRA remedies (15 U.S.C. §§ 1681n, 1681o), a victim may pursue UCSPA claims under Utah Code § 13-11-19 for deceptive or unconscionable conduct by furnishers or merchants who facilitated the fraud, and common-law claims (negligence, conversion, intentional infliction of emotional distress).
• Active-duty members. Service members may use an active-duty alert (15 U.S.C. § 1681c-1(c)) which lasts one year and suppresses prescreening for two.
• Utah Cyber Center breach reporting. As of 2024 amendments (S.B. 98), entities reporting a breach affecting 500+ Utah residents must notify both the Office of the Attorney General and the Utah Cyber Center.

6. SOURCES AND REFERENCES

• 15 U.S.C. § 1681a(q) — https://www.law.cornell.edu/uscode/text/15/1681a
• 15 U.S.C. § 1681c-2 (block) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 15 U.S.C. § 1681g(e) (records to victim) — https://www.law.cornell.edu/uscode/text/15/1681g
• 16 C.F.R. § 603.3 — https://www.ecfr.gov/current/title-16/chapter-I/subchapter-F/part-603
• Utah Code § 76-6-1102 (Identity fraud crime) — https://le.utah.gov/xcode/Title76/Chapter6/76-6-S1102.html
• Utah Code § 76-6-1103 (Penalties for identity fraud) — https://le.utah.gov/xcode/Title76/Chapter6/76-6-S1103.html
• Utah Code Title 13, Chapter 44 (Protection of Personal Information Act) — https://le.utah.gov/xcode/Title13/Chapter44/13-44.html
• Utah Code § 13-44-202 (Disclosure of system security breach) — https://le.utah.gov/xcode/Title13/Chapter44/13-44-S202.html
• Utah Code Title 13, Chapter 45 (Security freeze) — https://le.utah.gov/xcode/Title13/Chapter45/13-45.html
• Utah Code § 78B-5-705 (Sworn declaration in lieu of notarization) — https://le.utah.gov/xcode/Title78B/Chapter5/78B-5-S705.html
• Utah Identity Theft Reporting (IRIS) — https://idtheft.utah.gov
• Utah Cyber Center (breach reporting) — https://cybercenter.utah.gov
• Utah Attorney General — https://attorneygeneral.utah.gov
• FTC IdentityTheft.gov — https://www.identitytheft.gov
• IRS Form 14039 — https://www.irs.gov/forms-pubs/about-form-14039
• AnnualCreditReport.com — https://www.annualcreditreport.com

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Utah should review and customize the affidavit before submission, particularly where civil litigation against furnishers, CRAs, or the original breach source is contemplated.