Identity Theft Affidavit and Police Report Cover - Washington

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER LETTER — WASHINGTON

PART A — COVER LETTER (TO LAW ENFORCEMENT)

[VICTIM FULL LEGAL NAME]

[STREET ADDRESS]

[CITY, WA ZIP]

Telephone: [NUMBER]

Email: [EMAIL]

Date: [__/__/____]

[POLICE DEPARTMENT / SHERIFF'S OFFICE NAME]

Attn: Records / Identity Theft / Financial Crimes Unit

[STREET ADDRESS]

[CITY, WA ZIP]

RE: Request to File Identity Theft Report and to Take a Statement Pursuant to RCW § 9.35.040

Dear Officer / Records Custodian:

I am a Washington resident and victim of identity theft. Pursuant to RCW § 9.35.040, the law enforcement agency in the jurisdiction where I reside has authority and is required to take an identity theft report and provide me with a copy of the report or its complaint number.

Enclosed are:

1. The completed Washington Identity Theft Affidavit (Part B);
2. Photocopies of my government-issued photo ID and proof of residence;
3. Copies of fraudulent account statements or notices (where available);
4. The FTC IdentityTheft.gov report number: [________________________________];
5. [If applicable] A copy of the Notice of Data Breach received from [ENTITY] under RCW § 19.255.010, dated [__/__/____].

I respectfully request that the Department:

• Open an identity theft case under RCW § 9.35.020;
• Provide me with the case number and a certified copy of the report; and
• Forward referrals to any other jurisdiction in which fraudulent accounts were opened, as authorized by RCW § 9.35.040.

I remain available at the contact information above. Thank you for your assistance.

Respectfully,

[________________________________]

[VICTIM FULL LEGAL NAME]

PART B — WASHINGTON IDENTITY THEFT AFFIDAVIT

STATE OF WASHINGTON

COUNTY OF [_______________]

I, [VICTIM FULL LEGAL NAME], being first duly sworn (or alternatively declaring under penalty of perjury under the laws of the State of Washington pursuant to RCW § 9A.72.085), state as follows:

Section 1 — Victim Information

Section 2 — Discovery of Identity Theft

1. On or about [__/__/____], I discovered that my identifying information had been used without my authorization by an unknown person or persons.

2. I discovered the identity theft by: ☐ a credit-report alert; ☐ a bill or statement for an account I did not open; ☐ a debt-collection contact; ☐ denial of credit; ☐ a Notice of Data Breach under RCW § 19.255.010; ☐ a law-enforcement notification; ☐ other: [DESCRIBE].

3. [If a data breach is the suspected source:] On or about [__/__/____], I received a Notice of Data Breach from [ENTITY] under RCW § 19.255.010 disclosing that my [name / SSN / driver license / financial-account number / health information / passport / biometric data / other] was acquired by an unauthorized person. A copy of that notice is attached.

Section 3 — Fraudulent Accounts and Activity

The following accounts, transactions, or activities were opened or conducted without my knowledge, authorization, or consent:

I did not apply for, open, authorize, ratify, use, or benefit from any of the accounts or transactions listed above. I have not received any goods, services, money, or other benefit from any of these accounts.

Section 4 — Authorized Users and Suspects

4. I ☐ HAVE / ☐ HAVE NOT identified a suspect.

5. [If a suspect is identified:] The suspect's identity is [NAME, RELATIONSHIP IF KNOWN, ADDRESS, TELEPHONE]. The factual basis for naming this suspect is: [DESCRIBE].

6. No person had my permission or authority to use my identifying information to open or transact on the accounts listed in Section 3.

Section 5 — Steps Taken to Date

I have taken the following steps in response to the identity theft (check all that apply):

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

☐ Placed a security freeze with Equifax, Experian, and TransUnion (15 U.S.C. § 1681c-1(i); RCW § 19.182.170);

☐ Filed an FTC report at IdentityTheft.gov — Report Number: [________________________________];

☐ Notified each furnisher in writing and disputed the fraudulent accounts;

☐ Closed compromised bank, credit, or other accounts;

☐ Changed online passwords and security answers;

☐ Filed an IRS Identity Theft Affidavit (Form 14039), if tax-related;

☐ Notified the Social Security Administration, if SSN was misused;

☐ Notified the Washington Department of Licensing, if driver license was misused;

☐ Notified the U.S. Postal Inspection Service, if mail was involved;

☐ Notified the Washington State Attorney General Consumer Protection Division.

Section 6 — Demand for FCRA Block (15 U.S.C. § 1681c-2)

7. Pursuant to 15 U.S.C. § 1681c-2, each consumer reporting agency must block from any consumer report information that the consumer identifies as resulting from an alleged identity theft, no later than four (4) business days after receiving:

• (a) appropriate proof of identity;
• (b) a copy of an Identity Theft Report;
• (c) the consumer's identification of the information; and
• (d) a statement that the information is not information relating to any transaction by the consumer.

8. I hereby certify that the information identified in Section 3 of this Affidavit DID NOT result from any transaction by me. I demand that all consumer reporting agencies block this information pursuant to 15 U.S.C. § 1681c-2 and that all furnishers cease reporting it pursuant to 15 U.S.C. § 1681s-2(a)(6).

Section 7 — Washington Civil Remedies (RCW § 9.35.020(7))

9. Under RCW § 9.35.020(7), a person who violates Washington's identity theft statute is liable to the victim in a civil action for the greater of one thousand dollars ($1,000) or actual damages, including costs to repair the victim's credit record, plus reasonable attorney fees as determined by the court. I expressly reserve all civil claims and remedies under RCW § 9.35.020, RCW Chapter 19.182 (WA Fair Credit Reporting Act), RCW Chapter 19.86 (WCPA), and 15 U.S.C. §§ 1681 et seq.

Section 8 — Verification and Signature

I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct to the best of my knowledge.

Executed at [CITY, STATE] on this [____] day of [_______________], 20[____].

[________________________________]

[VICTIM FULL LEGAL NAME]

Notarization (Recommended Where Required by Recipient)

State of Washington

County of [_______________]

Subscribed and sworn to (or affirmed) before me this [____] day of [_______________], 20[____], by [VICTIM FULL LEGAL NAME], who is personally known to me or has provided satisfactory evidence of identity.

[________________________________]

Notary Public — State of Washington

Print Name: [________________________________]

My Commission Expires: [__/__/____]

PART C — DISTRIBUTION COVER LETTER (TO FURNISHERS / CRAs)

Sent via U.S. Certified Mail, Return Receipt Requested

Tracking No.: [________________________________]

Date: [__/__/____]

To: [FURNISHER / CONSUMER REPORTING AGENCY NAME AND ADDRESS]

RE: Identity Theft — Demand for Block / Removal Pursuant to 15 U.S.C. § 1681c-2 and § 1681s-2

Dear Compliance Officer:

I am a Washington resident and victim of identity theft. Enclosed is my Identity Theft Report consisting of (1) my sworn Washington Identity Theft Affidavit, and (2) a police report filed under RCW § 9.35.020 with [POLICE AGENCY], Case No. [________________________________], together with my FTC IdentityTheft.gov Report No. [________________________________].

Pursuant to 15 U.S.C. § 1681c-2 (for consumer reporting agencies) and 15 U.S.C. § 1681s-2(a)(6) (for furnishers), please:

1. Block / cease reporting all information identified as fraudulent in Section 3 of the enclosed Affidavit within four (4) business days of receipt;
2. Notify any other furnisher or consumer reporting agency to which you supplied the disputed information;
3. Provide me written confirmation of the action taken; and
4. Send me a free copy of all records relating to the fraudulent accounts pursuant to 15 U.S.C. § 1681g(e), within thirty (30) days.

Failure to comply will independently violate the FCRA and may give rise to claims under 15 U.S.C. § 1681n / § 1681o, RCW Chapter 19.182, RCW § 9.35.020(7), and the Washington Consumer Protection Act, RCW Chapter 19.86.

Sincerely,

[________________________________]

[VICTIM FULL LEGAL NAME]

PART D — WASHINGTON PRACTICE NOTES

• Police report jurisdiction. RCW § 9.35.040 requires the law enforcement agency in the victim's residence to take an identity-theft report regardless of where the underlying fraudulent activity occurred. Cite this statute if any agency declines.
• Identity Theft Report. Under FCRA, an "Identity Theft Report" requires (1) a copy of an official report filed with a federal, state, or local law enforcement agency that subjects the filer to penalties for false statements, and (2) additional information the agency reasonably requests. 15 U.S.C. § 1681a(q). FTC IdentityTheft.gov + a local police report together meet this definition.
• FCRA block (§ 1681c-2). CRAs must block within 4 business days of receipt. Furnishers must cease reporting once notified by a CRA or the consumer (§ 1681s-2(a)(6)).
• WA civil cause of action. RCW § 9.35.020(7) provides a private right of action for the greater of $1,000 or actual damages, credit-repair costs, and attorney fees. Plead identity theft in conjunction with WCPA claims (RCW § 19.86.020) and WA FCRA claims (RCW § 19.182.150).
• Data breach overlay. RCW § 19.255.010 requires any person or business that owns or licenses computerized data including personal information to notify affected Washington residents within 30 days of discovery (and to notify the WA AG if more than 500 Washington residents are affected). Save the breach notice — it documents the source of the compromised information.
• Security freeze. RCW § 19.182.170 grants Washington consumers the right to a free security freeze with each consumer reporting agency. Recommend placing a freeze immediately.
• Senior or vulnerable victim. Identity theft targeting a senior (60+) or vulnerable individual is automatically Identity Theft in the First Degree (Class B felony) under RCW § 9.35.020(2)(b), regardless of the dollar amount.
• IRS Form 14039. If the misuse involves tax returns or wages, file IRS Form 14039 (Identity Theft Affidavit). The IRS does not accept the FTC affidavit alone.
• WA AG complaint. File a parallel complaint with the Washington AG Consumer Protection Division (atg.wa.gov) — see ag_cfpb_complaint_pack.md in this directory.

PART E — SOURCES AND REFERENCES

• 15 U.S.C. § 1681c-2 (FCRA block) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 15 U.S.C. § 1681s-2 (furnisher duties) — https://www.law.cornell.edu/uscode/text/15/1681s-2
• 15 U.S.C. § 1681a(q) (Identity Theft Report definition) — https://www.law.cornell.edu/uscode/text/15/1681a
• RCW § 9.35.020 (Identity theft) — https://app.leg.wa.gov/rcw/default.aspx?cite=9.35.020
• RCW § 9.35.030 — https://app.leg.wa.gov/rcw/default.aspx?cite=9.35.030
• RCW § 9.35.040 (Reporting jurisdiction) — https://app.leg.wa.gov/rcw/default.aspx?cite=9.35.040
• RCW § 9A.72.085 (Unsworn declaration) — https://app.leg.wa.gov/rcw/default.aspx?cite=9A.72.085
• RCW Chapter 19.255 (Data breach) — https://app.leg.wa.gov/rcw/default.aspx?cite=19.255&full=true
• RCW Chapter 19.182 (WA FCRA) — https://app.leg.wa.gov/rcw/default.aspx?cite=19.182&full=true
• WA AG — Data Breach Notifications — https://www.atg.wa.gov/data-breach-notifications
• FTC IdentityTheft.gov — https://www.identitytheft.gov/
• IRS Form 14039 — https://www.irs.gov/forms-pubs/about-form-14039

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Sworn or notarized signatures may be required by some recipients. Send by certified mail and retain proofs of mailing and delivery.