Identity Theft Affidavit and Police Report Cover (Virginia)

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — VIRGINIA

TABLE OF CONTENTS

1. Part A — Police Report Cover Letter
2. Part B — Sworn Identity Theft Affidavit
3. Schedule 1 — Fraudulent Account / Transaction List
4. Schedule 2 — Document Inventory
5. Distribution Checklist
6. Virginia Practice Notes
7. Sources and References

PART A — POLICE REPORT COVER LETTER

[VICTIM FULL LEGAL NAME]

[STREET ADDRESS]

[CITY, STATE ZIP]

[PHONE] | [EMAIL]

Date: [__/__/____]

To:

[LOCAL LAW-ENFORCEMENT AGENCY — e.g., Fairfax County Police Department / Richmond Police Department]

Attn: Records Division / Identity-Theft Liaison

[STREET ADDRESS]

[CITY, STATE ZIP]

RE: Request to File Identity-Theft Report under Va. Code § 18.2-186.3

Dear Officer / Records Custodian:

I am the victim of identity theft as defined under Va. Code § 18.2-186.3 and 18 U.S.C. § 1028. I respectfully request that this letter, the attached Sworn Identity Theft Affidavit, the FTC IdentityTheft.gov Report (Report No. [________________________________]), and the supporting documents listed in Schedule 2 be filed as a formal police report under your local incident-reporting system.

I make this request for the following purposes recognized by federal and Virginia law:

• To establish the predicate "police report" required for FCRA identity-theft blocks under 15 U.S.C. § 1681c-2;
• To support a petition for expungement of false identity information under Va. Code § 18.2-186.5 and § 19.2-392.2;
• To enable the Virginia Office of the Attorney General to issue an Identity Theft Passport pursuant to Va. Code § 18.2-186.5, which will be noted on my driver abstract by the Virginia Department of Motor Vehicles;
• To support restitution and victim-assistance efforts under Va. Code § 18.2-186.3(F);
• To support civil claims that may arise under the Virginia Consumer Protection Act, Va. Code § 59.1-196 et seq., and the FCRA.

I have, to the best of my knowledge, included all material facts known to me regarding the identity theft. I do not authorize and have never authorized the transactions or accounts listed in Schedule 1.

I will cooperate fully with any investigation. Please assign an incident number and provide me with a certified or sealed copy for my records and for distribution to creditors and consumer reporting agencies.

Respectfully,

[________________________________]

[VICTIM NAME]

Acknowledgment for Law Enforcement Use Only

PART B — SWORN IDENTITY THEFT AFFIDAVIT

COMMONWEALTH OF VIRGINIA

CITY / COUNTY OF [_______________], to wit:

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

1. Affiant Identification

1.1. My full legal name is [________________________________].

1.2. I currently reside at [STREET ADDRESS, CITY, STATE ZIP].

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

1.4. The last four digits of my Social Security Number are [XXXX]. (Full SSN to be provided separately under seal upon law-enforcement or court request.)

1.5. My telephone number is [________________________________] and my email address is [________________________________].

2. Statement of Identity Theft

2.1. I am the victim of identity theft. Without my authorization, knowledge, or consent, an unknown person or persons (or a known person whose identity is set forth in Paragraph 2.6) used my "identifying information" within the meaning of Va. Code § 18.2-186.3(C) — including but not limited to my name, date of birth, Social Security Number, driver's license number, financial account numbers, and other personal data — to obtain money, credit, goods, services, identification documents, or benefits.

2.2. I first discovered the identity theft on or about [__/__/____] when I [describe how discovery occurred — e.g., received a credit-card statement for an account I never opened; received a collection call regarding an unknown debt; reviewed my credit report and saw unfamiliar accounts].

2.3. The identity theft has caused me actual financial loss in the approximate amount of $[AMOUNT], in addition to time, emotional distress, and harm to my creditworthiness.

2.4. I have never authorized any other person to open accounts, obtain credit, file tax returns, or transact business in my name in connection with the items listed in Schedule 1.

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

2.6. [IF KNOWN] I [do / do not] know or suspect the perpetrator. The person I suspect is [NAME, RELATIONSHIP, LAST KNOWN ADDRESS], for the following reasons: [describe].

3. Mitigation Steps Taken

3.1. I have placed a [fraud alert / extended fraud alert / security freeze] with the three nationwide consumer reporting agencies (Equifax, Experian, TransUnion) on [__/__/____].

3.2. I have filed a report with the Federal Trade Commission at IdentityTheft.gov, Report No. [________________________________], on [__/__/____].

3.3. I have notified each affected creditor in writing as set forth in Schedule 1.

3.4. I have [filed / requested to file] a police report with [AGENCY], Incident No. [________________________________], on [__/__/____].

3.5. I will request an Identity Theft Passport from the Virginia Office of the Attorney General pursuant to Va. Code § 18.2-186.5.

4. Requests to Creditors and Consumer Reporting Agencies

4.1. FCRA Block. Pursuant to 15 U.S.C. § 1681c-2 (FCRA § 605B), I demand that each consumer reporting agency block the reporting of any information arising from the identity theft listed in Schedule 1, within four business days of receipt of this affidavit and the accompanying police report.

4.2. Furnisher Cease. Pursuant to 15 U.S.C. § 1681s-2(a)(6), I demand that each furnisher cease furnishing information about the fraudulent accounts to any consumer reporting agency.

4.3. Document Production. Pursuant to 15 U.S.C. § 1681g(e), I request that each creditor provide me, within 30 days, copies of all application records and business transaction records relating to the fraudulent accounts.

4.4. Account Closure. I request that each creditor close the fraudulent accounts and provide written confirmation that I am not liable for any charges, fees, or balances.

5. Breach Notification (If Applicable)

5.1. [IF KNOWN] I have reason to believe the identity theft resulted from a data breach involving [ENTITY NAME]. The entity provided breach notification dated [__/__/____] pursuant to Va. Code § 18.2-186.6, a copy of which is attached as Exhibit [___].

6. Affirmation

6.1. The statements above and in the attached schedules are true and correct to the best of my knowledge and belief, made under penalty of perjury under the laws of the Commonwealth of Virginia and 28 U.S.C. § 1746.

6.2. I understand that knowingly making a false statement in this affidavit may subject me to criminal penalties under Va. Code § 18.2-434 (perjury) and § 18.2-461 (false reports to law enforcement).

[________________________________]

[VICTIM NAME], Affiant

Notary Acknowledgment

COMMONWEALTH OF VIRGINIA

CITY / COUNTY OF [_______________], to wit:

Subscribed and sworn to before me this [____] day of [_______________], 20[____], by [VICTIM NAME], who is [personally known to me / proved to me on the basis of satisfactory evidence — driver's license / passport] to be the person whose name is subscribed to this instrument.

[________________________________]

Notary Public

Registration No.: [________________________________]

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

(SEAL)

SCHEDULE 1 — FRAUDULENT ACCOUNT / TRANSACTION LIST

SCHEDULE 2 — DOCUMENT INVENTORY

The following documents are attached and incorporated by reference:

• ☐ Government-issued photo ID (driver's license, passport, or state ID)
• ☐ Proof of current address (utility bill, lease, mortgage statement)
• ☐ Social Security card or Form SSA-7004 (under seal)
• ☐ FTC IdentityTheft.gov Report (Report No. [________________])
• ☐ Police report or law-enforcement incident receipt
• ☐ Credit reports from Equifax, Experian, TransUnion (with disputed items circled)
• ☐ Fraud alert / security-freeze confirmations
• ☐ Dunning letters or collection notices
• ☐ Correspondence with creditors
• ☐ Breach notification letters (Va. Code § 18.2-186.6), if applicable
• ☐ [OTHER]

DISTRIBUTION CHECKLIST

• ☐ Local law enforcement — original cover letter, affidavit, schedules
• ☐ Federal Trade Commission — IdentityTheft.gov report (online)
• ☐ Virginia Office of the Attorney General — request for Identity Theft Passport, with police report or court order under § 19.2-392.2
• ☐ Equifax — Disputes / Fraud, P.O. Box 105069, Atlanta, GA 30348 — https://www.equifax.com/personal/credit-report-services/credit-fraud-alerts/
• ☐ Experian — P.O. Box 9554, Allen, TX 75013 — https://www.experian.com/fraud/center.html
• ☐ TransUnion — P.O. Box 2000, Chester, PA 19016 — https://www.transunion.com/fraud-alerts
• ☐ Each affected creditor — certified mail, return receipt
• ☐ Internal Revenue Service — Form 14039 (Identity Theft Affidavit), if tax-related
• ☐ Social Security Administration — if SSN misuse suspected
• ☐ Virginia DMV — if driver's-license-number misuse, request flag and Identity Theft Passport notation
• ☐ U.S. Postal Inspection Service — if mail involved
• ☐ CFPB — if a financial institution or CRA fails to block / correct

VIRGINIA PRACTICE NOTES

• Identity Theft Passport. Va. Code § 18.2-186.5 authorizes the Virginia OAG to issue an Identity Theft Passport upon submission of either (i) a court order obtained under § 19.2-392.2 or (ii) a police report. Passport notation is forwarded to the Virginia DMV and noted on the driver abstract, providing law-enforcement officers a quick means of confirming identity-theft status during traffic stops or warrant checks.
• Breach notification. Va. Code § 18.2-186.6 requires entities that own or license computerized data to notify the Virginia OAG and affected residents "without unreasonable delay" after a breach involving unencrypted personal information that has caused, or is reasonably believed to cause, identity theft or fraud. The OAG may impose a civil penalty up to $150,000 per breach. Individuals may recover direct economic damages under § 18.2-186.6(I).
• Criminal penalties. Identity theft under § 18.2-186.3 is a Class 1 misdemeanor, escalating to a Class 6 felony if loss is $1,000 or more or on a second or subsequent conviction. Restitution is mandatory under § 18.2-186.3(F).
• Civil remedy under § 18.2-186.3:1. This section creates a separate cause of action against consumer reporting agencies that knowingly violate identity-theft block requirements with respect to a Virginia resident.
• FCRA blocking. Submission of (a) the affidavit, (b) a police or law-enforcement report, and (c) proof of identity satisfies 15 U.S.C. § 1681c-2 and triggers a four-business-day block obligation. CRA failure to block is independently actionable.
• Statute of limitations. Civil identity-theft and FCRA claims are subject to the FCRA's 2-years-from-discovery / 5-years-from-violation limit (15 U.S.C. § 1681p) and Virginia's general personal-property tort SOL of 5 years (Va. Code § 8.01-243(B)) for property-based torts.
• Judicial expungement. A petition under § 19.2-392.2 may be filed in the circuit court of the petitioner's residence to expunge false identity information from criminal records. The petition triggers issuance of an Identity Theft Passport and DMV notation.
• Tax-related identity theft. File IRS Form 14039 and obtain an IP PIN for future filings.

SOURCES AND REFERENCES

• Va. Code § 18.2-186.3 (Identity theft) — https://law.lis.virginia.gov/vacode/title18.2/chapter6/section18.2-186.3/
• Va. Code § 18.2-186.5 (Expungement; Identity Theft Passport) — https://law.lis.virginia.gov/vacode/title18.2/chapter6/section18.2-186.5/
• Va. Code § 18.2-186.6 (Breach notification — Personal Information Privacy Act) — https://law.lis.virginia.gov/vacode/title18.2/chapter6/section18.2-186.6/
• Va. Code § 19.2-392.2 (Expungement order petition) — https://law.lis.virginia.gov/vacode/title19.2/chapter23.1/section19.2-392.2/
• 15 U.S.C. § 1681c-2 (FCRA identity-theft block) — https://www.govinfo.gov/app/details/USCODE-2023-title15
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• Virginia OAG — Identity Theft Passport — https://www.oag.state.va.us/programs-initiatives/services-for-victims/identity-theft-passport
• IRS Form 14039 — https://www.irs.gov/forms-pubs/about-form-14039
• CFPB Identity Theft resources — https://www.consumerfinance.gov/consumer-tools/fraud/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. False statements in a sworn affidavit or police report may carry criminal liability. Consult a Virginia-licensed attorney for case-specific guidance.