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IDENTITY THEFT COMPLAINT FORM

    

Office of the Indiana Attorney General

  = Required Information

1. Your Information

4/20/2014 ]
You may refuse to provide your SSN and will not be penalized. However, disclosing your SSN will assist our Office in investigating your complaint and working with law enforcement. If you do provide your SSN, by signing this form you expressly consent to the disclosure of your SSN for investigative purposes in accordance with Indiana Code § 4-1-10-5(2).

2. Financial Institution Information

3. Law Enforcement Information

If yes:
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4. Crime Details

4/20/2014 ]
How did you become aware of the identity crime?









5. Identity Theft Complaint Summary Please provide a summary of your identity theft complaint. Please list all fraudulent activity that you are aware of and the dates, times, locations and addresses where fraudulent applications or purchases were made (retailers, banks, etc.) List events in chronological order, if possible. Please be concise and state the facts. You may attach a separate sheet if additional space is needed.

  

6. Credit Report Information

If yes, please check all that you have requested a report from:
Please upload complete copies of the reports per the instructions at the bottom of this page.Please attach complete copies of the reports to this form. A credit report will assist you in determining how many fraudulent accounts may have been opened using your information. It will also improve our ability to investigate your case. You can order your free credit report by calling 1-877-322-8228 or going to www.annualcreditreport.com

7. Consent

Do you consent to disclosing the following information to the public?

8. Consent and Verification

I affirm, under the penalties for perjury, that the foregoing representations, and those in all attachments that were prepared by me, are true. The information I have provided in this complaint form is based upon my personal knowledge. I consent to the release of any relevant information to the Identity Theft Unit. If I do provide my Social Security Number, I expressly consent to the disclosure of my Social Security Number in accordance with Indiana Code § 4-1-10-5(2). By filing this complaint, I understand that the Attorney General is not my private attorney, but enforces state consumer protection laws. I also agree to assist in the investigation and understand that I may be called to testify in court to the facts stated in this complaint.
4/20/2014 ]

9. Consent to correspondence by Email

Do you consent to the Consumer Protection Division sending you correspondence related to this complaint to your email address? If yes, you will not be mailed such correspondence via the U.S. Postal Service. If you select Yes please enter the email address we should use to send correspondence even if it is the same as the email address you entered earlier.
 
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