Identity Theft Affidavit and Police Report Cover - West Virginia

IDENTITY THEFT AFFIDAVIT AND POLICE REPORT COVER — WEST VIRGINIA

1. POLICE REPORT COVER LETTER

[CONSUMER FULL NAME]

[STREET ADDRESS]

[CITY, WV ZIP]

[PHONE] | [EMAIL]

Date: [__/__/____]

[POLICE DEPARTMENT / SHERIFF'S OFFICE NAME]

Attn: Records Division / Identity Theft / Fraud Unit

[STREET ADDRESS]

[CITY, WV ZIP]

Re: Request to Take Identity Theft Report and Issue Police Report Number

To the Officer in Charge:

I am a victim of identity theft and respectfully request that your department take a formal police report and issue a report number that I may use for federal Fair Credit Reporting Act blocking under 15 U.S.C. § 1681c-2 and for disputes with creditors and credit reporting agencies.

The conduct I am reporting violates West Virginia law, including:

• W. Va. Code § 61-3-54 — Taking the identity of another person (felony where applicable);
• W. Va. Code § 61-3-54a — Fraudulent use of access devices and credit cards (where applicable); and
• 18 U.S.C. § 1028 — Federal identity theft (concurrent jurisdiction may apply).

Pursuant to FTC guidance and the federal Identity Theft Assistance Act, law enforcement is encouraged to take a report regardless of whether a suspect has been identified. The report is essential for me to remediate financial harm.

I am providing the following supporting documents (and have signed the attached FTC-compliant Identity Theft Affidavit):

☐ Government-issued photo identification;

☐ Proof of West Virginia residence (utility bill, lease, or similar);

☐ FTC IdentityTheft.gov Identity Theft Report (Report Number: [________________________________]);

☐ Copies of fraudulent account statements, collection letters, or breach notices;

☐ Sworn Identity Theft Affidavit (below).

Please provide me with the report number and a copy of the report when complete.

Sincerely,

[________________________________]

[CONSUMER FULL NAME]

2. SWORN IDENTITY THEFT AFFIDAVIT

STATE OF WEST VIRGINIA

COUNTY OF [____________________]

I, [CONSUMER FULL NAME], being first duly sworn, depose and state under oath as follows:

2.1. Identity of Affiant

1. My full legal name is [________________________________].
2. My date of birth is [__/__/____].
3. My current residence address is [STREET, CITY, WV ZIP], where I have resided since [__/__/____].
4. The last four digits of my Social Security Number are [XXX-XX-____].
5. The last four digits of my driver's license / WV ID are [____].

2.2. Statement of Identity Theft

6. I am the victim of identity theft. Without my knowledge, consent, or authorization, an unknown person (or persons) has used my personal identifying information — including my [name / Social Security Number / date of birth / address / driver's license number / financial account information] — to [open accounts / make charges / obtain credit / apply for employment / file tax returns / commit other fraud] in my name.

7. I first learned of the identity theft on or about [__/__/____] when [describe — e.g., received a collection letter, denied for credit, received a credit card statement for an account I never opened, was contacted by a creditor].

2.3. Fraudulent Accounts / Transactions

8. The following accounts, charges, or transactions were not opened or authorized by me:

9. I did not apply for, open, sign for, or authorize any of the above accounts, charges, or transactions, and I did not benefit from any of them.

10. I have not given anyone permission to use my personal identifying information for any of the above purposes.

2.4. Suspect Information (If Known)

11. [I do not know who the perpetrator(s) is / are.] OR [I suspect the following individual(s) may have committed the identity theft: NAME, RELATIONSHIP, ADDRESS, BASIS FOR SUSPICION.]

2.5. Documents Lost, Stolen, or Compromised

12. My personal information was compromised in connection with [describe — e.g., a stolen wallet on [DATE]; a lost mailbox key; the [NAME] data breach disclosed on [DATE]; a phishing email; a known database breach; a family-member theft].

13. [If applicable] I received a breach notification letter dated [__/__/____] from [ENTITY NAME] disclosing that my personal information was accessed by an unauthorized person, pursuant to W. Va. Code § 46A-2A-102. A copy is attached as Exhibit 1.

2.6. Damage Claims

14. As a direct and proximate result of the identity theft, I have suffered financial harm including [unauthorized charges, denial of credit, increased interest rates, debt collection harassment, time lost remediating, fees, lost wages, emotional distress, and credit-report damage] in an amount of approximately $[________].

2.7. Reporting and Cooperation

15. I have reported, or intend to report, this identity theft to:

☐ Federal Trade Commission via IdentityTheft.gov (Report No. [______________]);

☐ Local police department / sheriff (Report No. [______________]);

☐ The three nationwide credit reporting agencies (Equifax, Experian, TransUnion);

☐ Each affected creditor and debt collector;

☐ The Social Security Administration (if SSN was misused);

☐ The Internal Revenue Service via Form 14039 (if tax-related);

☐ The West Virginia Attorney General Consumer Protection Division.

16. I will cooperate fully with law enforcement investigation and prosecution of the perpetrator(s) under W. Va. Code § 61-3-54 and applicable federal law.

2.8. Verification of Truth

17. The information I have provided in this Affidavit is true and correct to the best of my knowledge. I understand that knowingly making a false statement on this Affidavit may subject me to criminal prosecution, including under W. Va. Code § 61-5-1 (perjury) and 18 U.S.C. § 1001.

[________________________________]

[CONSUMER FULL NAME], Affiant

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public, State of West Virginia

(My Commission Expires: [_______________])

3. CREDITOR / FURNISHER NOTICE LETTER (Use One Copy Per Affected Creditor)

[CREDITOR / FURNISHER NAME]

Attn: Identity Theft / Fraud Department

[ADDRESS]

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

Re: Identity Theft — Demand to Cease Collection, Block Furnishing, and Provide Records under 15 U.S.C. § 1681g(e)

To Whom It May Concern:

I am a victim of identity theft. I did not apply for, open, sign for, or authorize the account(s) and/or transaction(s) listed below, and I am not liable for any associated charges or balances.

Account No.: [________________________________]

Amount Disputed: $[________]

Pursuant to 15 U.S.C. § 1681c-2, 15 U.S.C. § 1681s-2(a)(6) (furnisher duties upon notice of identity theft), and W. Va. Code § 61-3-54, you are required to:

1. Cease all collection activity on the disputed account(s) pending investigation;
2. Block or remove the disputed information from any credit reporting you have made;
3. Refrain from re-furnishing the disputed information to any consumer reporting agency;
4. Provide me, free of charge, copies of all application and transaction records relating to the disputed account(s) within 30 days of this request, pursuant to 15 U.S.C. § 1681g(e);
5. Notify any debt collector to whom the disputed account has been transferred, sold, or referred that the account is the subject of an identity-theft claim.

Enclosed are:

☐ My sworn Identity Theft Affidavit;

☐ FTC IdentityTheft.gov Identity Theft Report (Report No. [______________]);

☐ Police report (Report No. [______________]) from [POLICE DEPARTMENT];

☐ Government-issued photo identification (with sensitive numbers redacted);

☐ Proof of address (utility bill or similar).

Failure to comply with the FCRA's identity-theft provisions may give rise to claims for actual damages, statutory damages of up to $1,000, punitive damages, and attorney's fees under 15 U.S.C. § 1681n and § 1681o, and may constitute an unfair or deceptive act or practice in violation of W. Va. Code § 46A-6-104 and a violation of W. Va. Code §§ 46A-2-127 and 46A-2-128 (debt collection provisions).

I reserve all rights and remedies. Please direct all further communications to me at the address above (or to my attorney, if represented).

Sincerely,

[________________________________]

[CONSUMER FULL NAME]

Date: [__/__/____]

4. CREDIT REPORTING AGENCY (CRA) BLOCK REQUEST LETTER

[CRA NAME — Equifax / Experian / TransUnion]

[ADDRESS — see CRA's published identity-theft mailing address]

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

Re: Request to Block Information Resulting from Identity Theft (15 U.S.C. § 1681c-2) and Add Extended Fraud Alert (15 U.S.C. § 1681c-1(b))

To Whom It May Concern:

I am a victim of identity theft and request that you (1) BLOCK the information identified below pursuant to 15 U.S.C. § 1681c-2; (2) place an EXTENDED FRAUD ALERT on my consumer file pursuant to 15 U.S.C. § 1681c-1(b) (7 years); and (3) provide me with a free copy of my consumer file pursuant to 15 U.S.C. § 1681c-1(c).

Items to Block:

Enclosed:

☐ Sworn Identity Theft Affidavit;

☐ FTC IdentityTheft.gov Identity Theft Report (Report No. [______________]);

☐ Police report (Report No. [______________]);

☐ Government-issued photo identification;

☐ Proof of address.

Sincerely,

[________________________________]

[CONSUMER FULL NAME]

Date: [__/__/____]

5. WEST VIRGINIA PRACTICE NOTES

• Principal WV statute. W. Va. Code § 61-3-54 ("Taking the identity of another person") criminalizes knowingly taking the name, birth date, Social Security number, or other identifying information of another person, without consent, with intent to fraudulently represent that he or she is the other person to make financial or credit transactions or obtain employment. The statute provides for confinement in the penitentiary and/or fine. Verify the most current penalty range; the statute has been amended.
• Companion WV statute. W. Va. Code § 61-3-54a addresses fraudulent use of access devices and credit cards.
• Police-report leverage. WV law enforcement is required to take an identity-theft report under FTC and federal best-practice guidance, even where the suspect is unknown. If a department refuses, request a supervisor or contact the WV Attorney General's office.
• Breach notification overlay. W. Va. Code § 46A-2A-101 et seq. (effective 2008, as amended) requires entities owning or licensing computerized personal information to notify affected WV residents of a breach without unreasonable delay. The AG has exclusive enforcement authority and may seek civil penalties (up to $150,000 per breach) for repeated and willful violations. If the consumer received a breach notice, preserve it as evidence and attach to the affidavit.
• Substitute notice triggers. Under § 46A-2A-102, substitute notice is permitted if cost exceeds $50,000, the affected class exceeds 100,000 persons, or contact information is insufficient.
• CRA notification when over 1,000 affected. § 46A-2A-102 requires notification of nationwide consumer reporting agencies when more than 1,000 persons are notified of a breach.
• Security freeze (free). WV consumers may place, lift, or remove a security freeze with each CRA at no charge under federal law (Economic Growth, Regulatory Relief, and Consumer Protection Act of 2018, codified at 15 U.S.C. § 1681c-1(i)).
• Tax-related identity theft. File IRS Form 14039 and an FTC report. Consider an Identity Protection PIN (IP PIN) through IRS.gov.
• Family-member identity theft. If the suspect is a relative, the FTC affidavit must still be submitted; do not omit the suspect's identity. WV courts may impose restitution under § 61-3-54.
• Civil remedies. In addition to FCRA claims, victims may pursue WV common-law claims (invasion of privacy, conversion, fraud) and WVCCPA claims under § 46A-6-104 against businesses that engaged in deceptive verification or collection practices.
• Statute of limitations on civil claims. WV's general tort SOL is two years (W. Va. Code § 55-2-12); FCRA actions are governed by the federal SOL in 15 U.S.C. § 1681p (earlier of 2 years from discovery or 5 years from violation).
• Attorney General contact. WV AG Consumer Protection Hotline: 1-800-368-8808; ago.wv.gov; [email protected].

6. SOURCES AND REFERENCES

• W. Va. Code § 61-3-54 (taking identity of another person) — https://code.wvlegislature.gov/61-3-54/
• W. Va. Code § 61-3-54a (fraudulent use of access devices) — https://code.wvlegislature.gov/61-3-54a/
• W. Va. Code Article 46A-2A (Breach of Security of Consumer Information) — https://code.wvlegislature.gov/46A-2A/
• W. Va. Code § 46A-2A-101 (definitions) — https://code.wvlegislature.gov/46A-2A-101/
• W. Va. Code § 46A-2A-102 (notice of breach) — https://code.wvlegislature.gov/46A-2A-102/
• W. Va. Code § 46A-6-104 (unfair or deceptive acts or practices) — https://code.wvlegislature.gov/46A-6-104/
• 15 U.S.C. § 1681c-2 (block of identity-theft information) — https://www.law.cornell.edu/uscode/text/15/1681c-2
• 15 U.S.C. § 1681c-1 (fraud alerts and active duty alerts) — https://www.law.cornell.edu/uscode/text/15/1681c-1
• 15 U.S.C. § 1681g(e) (information available to victims) — https://www.law.cornell.edu/uscode/text/15/1681g
• 15 U.S.C. § 1681s-2 (furnisher duties) — https://www.law.cornell.edu/uscode/text/15/1681s-2
• 18 U.S.C. § 1028 (federal identity theft) — https://www.law.cornell.edu/uscode/text/18/1028
• FTC IdentityTheft.gov — https://www.identitytheft.gov
• FTC Identity Theft Recovery Steps — https://consumer.ftc.gov/features/identity-theft
• WV AG Identity Theft Prevention — https://ago.wv.gov/consumerprotection/Pages/Identity-Theft-Prevention.aspx
• WV Attorney General Consumer Protection Division — https://ago.wv.gov/consumer-protection-and-antitrust-division
• IRS Form 14039 (Identity Theft Affidavit) — https://www.irs.gov/forms-pubs/about-form-14039
• Annual Credit Report (free) — https://www.annualcreditreport.com

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Consumers should consult an attorney licensed in West Virginia for personalized advice. Laws and regulations change frequently; verify all authorities before relying on this template.