Wisconsin Identity Theft Affidavit and Police Report Cover

WISCONSIN IDENTITY THEFT AFFIDAVIT AND POLICE-REPORT COVER

TABLE OF CONTENTS

1. Cover Page — Police Report Request
2. Affidavit — Sworn Statement of Identity Theft
3. Schedule A — Fraudulent Accounts and Charges
4. Schedule B — Personal Information Compromised
5. Schedule C — Wis. Stat. § 134.98 Breach Notices Received
6. Notarization
7. FCRA Block Demand to Consumer Reporting Agencies
8. Furnisher Block Demand
9. Wisconsin Practice Notes
10. Sources and References

1. COVER PAGE — POLICE REPORT REQUEST

TO: [LAW ENFORCEMENT AGENCY NAME]

Address: [STREET, CITY, WI ZIP]

Date: [DATE]

FROM: [VICTIM FULL LEGAL NAME]

Address: [STREET, CITY, WI ZIP]

Phone: [NUMBER] | Email: [EMAIL]

Re: Request for Identity-Theft Police Report — Wis. Stat. § 943.201(4)

I am the victim of identity theft. Pursuant to Wis. Stat. § 943.201(4), I request that your agency prepare a written report on the alleged unauthorized use of my personal identifying information described in the attached sworn affidavit. I respectfully request:

☐ A report number be assigned;

☐ A copy of the report be provided to me promptly for use under 15 U.S.C. § 1681c-2 (FCRA blocking) and 15 U.S.C. § 1681s-2(a)(6);

☐ The matter be referred to the appropriate investigative unit;

☐ Confirmation in writing that this submission has been received.

2. AFFIDAVIT — SWORN STATEMENT OF IDENTITY THEFT

STATE OF WISCONSIN

COUNTY OF [COUNTY]

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

2.1. I am over the age of 18, am a resident of [CITY, COUNTY], Wisconsin, and competent to make this affidavit. I have personal knowledge of the matters stated below.

2.2. Date of birth: [__/__/____]. Last four digits of Social Security number: XXX-XX-[####]. Driver license / state ID number: [NUMBER, STATE].

2.3. Discovery. On or about [DATE], I discovered that my personal identifying information had been used without my authorization. The circumstances of discovery were: [describe — credit-report alert, denial of credit, collection call, mail received, breach notice].

2.4. Unauthorized use. I did not authorize and have not ratified the accounts, applications, transactions, or other uses listed in Schedule A. Each constitutes an unauthorized use of my personal identifying information within the meaning of Wis. Stat. § 943.201(2).

2.5. Information compromised. The personal identifying information compromised is described in Schedule B, and includes one or more of the categories enumerated in Wis. Stat. § 943.201(1)(b).

2.6. Breach notice. I [have / have not] received a notice under Wis. Stat. § 134.98 from one or more entities concerning unauthorized acquisition of my personal information. Copies, if any, are attached as Schedule C.

2.7. No relationship with suspect. I do not know the person(s) responsible, OR I have the following relationship: [describe]. I did not provide my personal identifying information to that person and did not authorize its use.

2.8. No benefit received. I did not receive goods, services, money, credit, or any other benefit from the fraudulent accounts or transactions identified in Schedule A.

2.9. Mitigation. Upon discovery, I took the following steps: [fraud alert with one CRA; credit freezes under Wis. Stat. § 100.54; notice to financial institutions; change of passwords; change of mailing address; submitted IRS Form 14039; other].

2.10. FCRA Identity Theft Report. I submit this affidavit, together with the police report referenced above, to constitute an "identity theft report" within the meaning of 15 U.S.C. § 1681a(q)(4) and 16 C.F.R. § 603.3, and I understand that knowingly making false statements in this affidavit may subject me to criminal penalties.

2.11. Truth. The foregoing is true and correct to the best of my knowledge and belief, made under penalty of perjury under the laws of the State of Wisconsin and the United States.

[________________________________]

[VICTIM NAME] — Affiant

3. SCHEDULE A — FRAUDULENT ACCOUNTS AND CHARGES

4. SCHEDULE B — PERSONAL INFORMATION COMPROMISED

Check all that apply (categories tracked to Wis. Stat. § 943.201(1)(b) and § 134.98(1)(b)):

☐ Social Security number

☐ Driver license or Wisconsin DOT-issued identification number

☐ Financial account number (depository, credit, debit, prepaid)

☐ Taxpayer identification number / ITIN

☐ Mother's maiden name

☐ DNA profile

☐ Electronic serial number / mobile identification number / IMEI

☐ Unique biometric data (fingerprint, voiceprint, retina/iris image)

☐ Username and password / security question and answer

☐ Medical or health insurance information

☐ Date of birth

☐ Employer-assigned identifier

☐ Other: [________________________________]

5. SCHEDULE C — WIS. STAT. § 134.98 BREACH NOTICES RECEIVED

6. NOTARIZATION

STATE OF WISCONSIN

COUNTY OF [COUNTY]

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

[________________________________]

[NOTARY NAME], Notary Public

State of Wisconsin

(My Commission Expires: [_______________])

[NOTARY SEAL]

7. FCRA BLOCK DEMAND TO CONSUMER REPORTING AGENCIES

TO: Equifax (P.O. Box 105069, Atlanta, GA 30348); Experian (P.O. Box 9554, Allen, TX 75013); TransUnion (P.O. Box 2000, Chester, PA 19016)

FROM: [VICTIM NAME]

Re: 15 U.S.C. § 1681c-2 — Block of Information Resulting From Identity Theft

Pursuant to 15 U.S.C. § 1681c-2, I demand that you BLOCK from my consumer file the items listed in Schedule A within four (4) business days of receipt of this notice. I attach:

• Identification (copy of driver license, utility bill);
• The Wisconsin police report (Report No. [________________________________]) prepared under Wis. Stat. § 943.201(4);
• The notarized identity-theft affidavit above;
• Statement that the items result from an alleged identity theft and have not been authorized by me.

Additionally, please:

☐ Place an extended fraud alert under 15 U.S.C. § 1681c-1(b) for seven (7) years;

☐ Confirm a security freeze under Wis. Stat. § 100.54 (no charge to Wisconsin consumers);

☐ Provide the names, addresses, and phone numbers of all furnishers of the blocked items per § 1681c-2(d);

☐ Provide me a free credit file disclosure and free report under 15 U.S.C. § 1681j(d).

8. FURNISHER BLOCK DEMAND

TO: [FURNISHER NAME AND ADDRESS]

Re: 15 U.S.C. § 1681s-2(a)(6) — Cease Furnishing Identity-Theft Information

Pursuant to 15 U.S.C. § 1681s-2(a)(6), I demand that you cease furnishing to any consumer reporting agency any information related to the accounts and transactions identified in Schedule A, which result from identity theft. The Wisconsin police report and notarized affidavit are enclosed.

I further demand that you:

☐ Reverse all charges, fees, and interest;

☐ Close any unauthorized accounts;

☐ Provide me, free of charge, copies of applications and transaction records pursuant to 15 U.S.C. § 1681g(e);

☐ Confirm in writing within 30 days the actions taken in response to this notice.

9. WISCONSIN PRACTICE NOTES

• Wis. Stat. § 943.201 is a Class H felony. Penalties include up to 6 years' imprisonment and fines up to $10,000 per violation; restitution to the victim is available under Wis. Stat. § 973.20.
• Mandatory police report. Wis. Stat. § 943.201(4) requires the local agency where the victim resides to prepare a report on the alleged violation. Reference this provision if an officer hesitates.
• Breach notification. Wis. Stat. § 134.98 requires notice within a reasonable time not exceeding 45 days; if 1,000+ Wisconsin residents are affected, the entity must also notify nationwide consumer reporting agencies. Failure to notify is enforceable by DATCP.
• Security freeze (no fee). Wis. Stat. § 100.54 allows free placement and lifting of a security freeze on consumer-reporting files for Wisconsin residents and identity-theft victims.
• Restitution. Wis. Stat. § 973.20 permits criminal restitution; pursue both civil claims and restitution in the criminal case.
• Civil claim. Identity-theft victims may also pursue common-law claims (conversion, fraud) and § 100.18 claims if the conduct included misrepresentations to "the public."
• DATCP intake. File parallel complaints with DATCP at https://datcp.wi.gov; the Bureau of Consumer Protection at 2811 Agriculture Drive, P.O. Box 8911, Madison, WI 53708-8911; (800) 422-7128; [email protected].
• FTC IdentityTheft.gov. File a federal report at https://www.identitytheft.gov to generate an FTC Identity Theft Report (also qualifies under 15 U.S.C. § 1681a(q)(4)).
• IRS tax-related identity theft. File IRS Form 14039 if returns or refunds are affected.

10. SOURCES AND REFERENCES

• Wis. Stat. § 943.201 — https://docs.legis.wisconsin.gov/statutes/statutes/943/III/201
• Wis. Stat. § 943.203 — https://docs.legis.wisconsin.gov/statutes/statutes/943
• Wis. Stat. § 134.98 — https://docs.legis.wisconsin.gov/statutes/statutes/134/98
• Wis. Stat. § 100.54 (Security freeze)
• Wis. Stat. § 973.20 (Restitution)
• 15 U.S.C. § 1681c-2 — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 15 U.S.C. § 1681s-2 — https://www.law.cornell.edu/uscode/text/15/1681s-2
• 15 U.S.C. § 1681c-1 (Fraud alerts) — https://www.law.cornell.edu/uscode/text/15/1681c-1
• DATCP ID Theft / Data Breach guide — https://datcp.wi.gov/Pages/Publications/IDTheftDataBreach607.aspx
• FTC IdentityTheft.gov — https://www.identitytheft.gov
• Wisconsin DOJ Office of Privacy Protection — https://www.doj.state.wi.us
• 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. A Wisconsin-licensed attorney should review your facts before this packet is submitted. Notarize the affidavit before sending.