Identity Theft Affidavit and Police Report Cover - Vermont

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER PACKET — VERMONT

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. Notice to Creditors and Consumer Reporting Agencies
8. Recovery Action Checklist
9. Vermont Practice Notes
10. Sources and References

1. COVER LETTER TO LAW ENFORCEMENT

Date: [__/__/____]

To: [POLICE DEPARTMENT / VERMONT STATE POLICE BARRACKS / SHERIFF'S DEPARTMENT]

Address: [STREET ADDRESS, CITY, VT ZIP]

Re: Report of Identity Theft Pursuant to 13 V.S.A. § 2030

Dear Officer / Records Custodian:

I, [VICTIM FULL LEGAL NAME], am the victim of identity theft as defined by 13 V.S.A. § 2030. I respectfully request that your agency take a written police report regarding the conduct described in the enclosed affidavit and supporting documentation.

Enclosed are:

1. My notarized Affidavit of Identity Theft;
2. A Schedule of Fraudulent Accounts and Transactions;
3. Copies of supporting documents (credit reports, account statements, security-breach notice, correspondence); and
4. Government-issued photo identification verifying my identity.

I respectfully request:

☐ A police-report case number;

☐ A copy of the completed report;

☐ Forwarding to the proper investigative agency if jurisdiction lies elsewhere (e.g., town of perpetrator's residence, or federal authorities under 18 U.S.C. §§ 1028, 1028A); and

☐ Any victim-services or follow-up contact information.

Thank you for your prompt attention.

Sincerely,

[________________________________]

[VICTIM NAME]

2. VICTIM INFORMATION

3. AFFIDAVIT OF IDENTITY THEFT (NOTARIZED)

STATE OF VERMONT

COUNTY OF [________________________________], ss.

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

3.1. I am over the age of eighteen, of sound mind, and competent to make this affidavit. The facts stated are within my personal knowledge and are true and correct.

3.2. I am a resident of [TOWN], [COUNTY] County, Vermont. My identifying information is set out in Section 2 above.

3.3. I am the victim of identity theft as defined by 13 V.S.A. § 2030. An unknown person (or persons) obtained, produced, possessed, used, sold, gave, or transferred my "personal identifying information" without my consent, with intent to (or knowingly or recklessly facilitating another to) commit a misdemeanor or felony.

3.4. I did not authorize any person to use my name, Social Security number, date of birth, address, financial-account numbers, driver's-license number, or other identifying information to obtain credit, goods, services, money, property, employment, medical care, or government benefits, or for any other purpose, except as listed in the chart at Section 4 below as "Authorized."

3.5. I first discovered the identity theft on or about [__/__/____] when [describe — e.g., received a collection call, reviewed credit report, received a bill, was denied credit, received a security-breach notice under 9 V.S.A. § 2435 from [ENTITY] dated [__/__/____], was contacted by employer or law-enforcement officer, etc.].

3.6. I have not been charged, convicted, or arrested for any conduct relating to the fraudulent activity described in Section 4 below, and I did not consent to or benefit from such conduct.

3.7. I do not know the perpetrator. [OR] I believe the perpetrator may be [name and relationship if known] based on [basis of belief].

3.8. I have taken or will promptly take the following actions:

☐ Filed a report with the Federal Trade Commission at IdentityTheft.gov (FTC Report Number: [________________________________]);

☐ Placed an initial 1-year fraud alert with one of the three nationwide consumer reporting agencies under 15 U.S.C. § 1681c-1;

☐ Placed a security freeze with each of Equifax, Experian, and TransUnion under 15 U.S.C. § 1681c-1(i) and 9 V.S.A. § 2480b;

☐ Notified each creditor or financial institution listed in Section 4;

☐ Filed this report with [LAW ENFORCEMENT AGENCY] on [__/__/____], Case No. [________________________________];

☐ Filed a complaint with the Vermont Attorney General Consumer Assistance Program (109 State Street, Montpelier, VT 05609; (800) 649-2424; [email protected]).

3.9. I make this affidavit so that creditors, banks, employers, consumer reporting agencies, and law-enforcement agencies will block, remove, investigate, and prosecute fraudulent activity associated with my identity, and so that the records of the fraudulent activity will not be attributed to me.

3.10. I understand that knowingly making a false statement in this affidavit may subject me to criminal prosecution under Vermont and federal law, including 13 V.S.A. § 2904 (false statements) and 18 U.S.C. § 1001.

Further, affiant sayeth not.

[________________________________]

[VICTIM NAME], Affiant

Date: [__/__/____]

ACKNOWLEDGMENT

State of Vermont

County of [________________________________], ss.

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

[________________________________]

Notary Public / Notarial Officer

Commission No.: [________________________________]

My commission expires: [__/__/____]

(Notary seal)

4. SCHEDULE OF FRAUDULENT ACCOUNTS AND TRANSACTIONS

Suspected medium of compromise (check all that apply):

☐ Stolen wallet/purse ☐ Mail theft ☐ Phishing email/text ☐ Phone scam ☐ Data breach (security-breach notice received under 9 V.S.A. § 2435 from [ENTITY] dated [__/__/____]) ☐ Lost/stolen device ☐ Skimmer/card cloning ☐ Insider/known person ☐ Unknown

5. DOCUMENTS ATTACHED / ENCLOSED

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

☐ Proof of current Vermont address (utility bill, lease, mortgage statement)

☐ FTC Identity Theft Report (IdentityTheft.gov)

☐ Credit reports from Equifax, Experian, TransUnion (with fraudulent items circled)

☐ Account statements showing fraudulent transactions

☐ Correspondence from creditors / collection agencies

☐ Security-breach notice received under 9 V.S.A. § 2435

☐ Affidavits from witnesses (if any)

☐ Other: [________________________________]

6. DEMAND FOR POLICE REPORT

I respectfully request that your agency take a written police report of the matter described in this packet and provide me a copy. Vermont law-enforcement agencies routinely take identity-theft reports from victims to facilitate civil remediation with creditors and consumer reporting agencies, even where investigative jurisdiction may rest with another agency.

If your agency lacks jurisdiction, I respectfully request that the report be forwarded to the appropriate Vermont State Police barracks, the U.S. Secret Service field office, the U.S. Postal Inspection Service (where mail or interstate carrier was used), or the Federal Bureau of Investigation, as applicable.

7. NOTICE TO CREDITORS AND CONSUMER REPORTING AGENCIES

A copy of this affidavit, together with a certified copy of the police report and the FTC Identity Theft Report, will be transmitted to each creditor and each nationwide consumer reporting agency.

Pursuant to the Fair Credit Reporting Act:

• 15 U.S.C. § 1681c-2 — CRAs must block information resulting from identity theft within four business days after receiving the consumer's identification, an Identity Theft Report, and the consumer's statement that the information is not the result of any transaction by the consumer;
• 15 U.S.C. § 1681s-2(a)(6) — Furnishers must cease furnishing information after notice that the information results from identity theft;
• 15 U.S.C. § 1681g(e) — Business entities must provide the victim, upon request and submission of an Identity Theft Report, with copies of application and transaction records relating to the identity theft, free of charge;
• 9 V.S.A. § 2480b — Vermont consumers are entitled to place security freezes on their credit reports without charge.

Failure to comply gives rise to private actions under the FCRA and may also constitute an unfair or deceptive act or practice under the Vermont Consumer Protection Act, 9 V.S.A. § 2453, with remedies including actual damages, attorney's fees, and exemplary damages up to three (3) times the consideration paid (9 V.S.A. § 2461(b)).

8. RECOVERY ACTION CHECKLIST

Within 24-72 hours:

☐ File FTC report at IdentityTheft.gov

☐ Place initial 1-year fraud alert with one CRA (the CRA must notify the other two)

☐ Contact each affected creditor's fraud department; close fraudulent accounts in writing

☐ Change passwords / PINs on all financial accounts

☐ File this affidavit with local Vermont law enforcement (police, sheriff, or VT State Police)

Within 30 days:

☐ Place a security freeze with each of Equifax, Experian, TransUnion (free under FCRA and 9 V.S.A. § 2480b)

☐ Submit Identity Theft Report packet to each CRA demanding § 1681c-2 block

☐ Send § 1681g(e) requests to creditors for application and transaction records

☐ File complaint with Vermont AG Consumer Assistance Program (CAP) at ago.vermont.gov/cap or by phone (800) 649-2424

☐ Notify Social Security Administration if SSN misused (1-800-269-0271)

☐ Notify Vermont Department of Motor Vehicles if Vermont driver's license / state ID misused (https://dmv.vermont.gov/)

☐ Report tax-related identity theft via IRS Form 14039 and notify Vermont Department of Taxes (https://tax.vermont.gov/help/identity-theft)

☐ Notify USPIS if mail theft suspected

Ongoing:

☐ Review credit reports quarterly

☐ Document every communication (date, time, person, content)

☐ Retain all certified-mail receipts

☐ Track all out-of-pocket expenses (potentially recoverable as restitution upon a § 2030 conviction or as damages in a § 2461(b) civil action against an enabling business)

9. VERMONT PRACTICE NOTES

• 13 V.S.A. § 2030 elements. Two distinct offenses: (i) obtaining or using personal identifying information with intent to commit a misdemeanor or felony; and (ii) knowingly or recklessly obtaining or using such information without consent and facilitating a third party's misdemeanor or felony. Penalties: up to 3 years and/or $5,000 for a first offense; up to 10 years and/or $10,000 for a second/subsequent offense involving a separate scheme.
• Definition of "personal identifying information." Expansive — includes name, address, DOB, SSN, motor-vehicle PIN, telephone number, financial-services account number, savings/checking/credit/debit numbers, picture, identification document, electronic ID number, educational/health-care/financial/credit/employment record, email address, computer-system password, and mother's maiden name. 13 V.S.A. § 2030(b)(2).
• No Vermont "identity theft passport." Unlike some states, Vermont does not maintain an AG-issued passport program. The FTC IdentityTheft.gov report (with police report) functions as the FCRA "Identity Theft Report" for blocking, fraud alerts, and creditor record requests.
• 9 V.S.A. § 2435 Security Breach Notice Act. Any "data collector" that owns or licenses computerized personally identifiable information or login credentials must, after discovery of a breach, notify the consumer "in the most expedient time possible and without unreasonable delay, but not later than 45 days after the discovery." Notice to the Vermont AG (or DFR if a financial institution) is also required, and the AG often publishes the notice. Demand and preserve any breach notice you have received — it is direct evidence of vector.
• Free credit freezes. 9 V.S.A. § 2480b authorizes Vermont consumers to place, lift, and remove security freezes at no charge with each nationwide CRA. This duplicates the federal right under 15 U.S.C. § 1681c-1(i) but provides a state-law claim if a CRA improperly charges.
• Civil claims against enablers. A business that fails to maintain reasonable security or fails to notify of a breach may be liable under 9 V.S.A. § 2453 (and § 2461(b)) where the failure caused the identity theft. Vermont AG enforcement and private VTCPA actions both available.
• FCRA private-action SOL. Two years from discovery, five years from violation. 15 U.S.C. § 1681p.
• VTCPA SOL. Six (6) years under the residual civil action SOL of 12 V.S.A. § 511 (verify with current case law).
• Restitution upon conviction. Vermont restitution statutes (13 V.S.A. § 7043) authorize courts to order restitution to crime victims for liquidated out-of-pocket loss, subject to the Restitution Unit's process.
• Active-duty servicemembers. May place an active-duty alert under 15 U.S.C. § 1681c-1(c) and obtain extended (7-year) alerts with an Identity Theft Report.

10. SOURCES AND REFERENCES

• 13 V.S.A. § 2030 (Identity theft) — https://legislature.vermont.gov/statutes/section/13/047/02030
• 9 V.S.A. § 2435 (Security Breach Notice Act) — https://legislature.vermont.gov/statutes/section/09/062/02435
• 9 V.S.A. ch. 62 (Protection of Personal Information) — https://legislature.vermont.gov/statutes/chapter/09/062
• 9 V.S.A. § 2480b (Security freezes) — https://legislature.vermont.gov/statutes/section/09/063/02480b
• Vermont Consumer Protection Act, 9 V.S.A. ch. 63 — https://legislature.vermont.gov/statutes/fullchapter/09/063
• Vermont Attorney General — Identity Theft — https://ago.vermont.gov/cap/scam-prevention-through-awareness-and-education/identity-theft
• Vermont Attorney General — Privacy and Data Security — https://ago.vermont.gov/privacy-data-security
• Vermont Attorney General — Data Breach Notifications — https://ago.vermont.gov/privacy-data-security/security-breaches
• Vermont Department of Financial Regulation — Data Breach Notifications — https://dfr.vermont.gov/about-us/legal-general-counsel/data-breach-notifications
• Vermont Department of Taxes — Identity Theft — https://tax.vermont.gov/help/identity-theft
• 18 U.S.C. § 1028 (federal identity-fraud statute) — https://www.law.cornell.edu/uscode/text/18/1028
• 15 U.S.C. § 1681c-1 (fraud alerts and freezes) — https://www.law.cornell.edu/uscode/text/15/1681c-1
• 15 U.S.C. § 1681c-2 (block of information resulting from identity theft) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 15 U.S.C. § 1681g(e) (consumer's right to records of identity theft) — https://www.law.cornell.edu/uscode/text/15/1681g
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• IRS Form 14039 (Identity Theft Affidavit) — https://www.irs.gov/forms-pubs/about-form-14039
• VTLawHelp.org — Identity Theft — https://www.vtlawhelp.org/identity-theft

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