Florida's Identity Theft Victim Kit

(22)
A copy of the report you filed with the police or sheriff’s department. If you are unable
to obtain a report or report number from the police, please indicate that in Item 19. Some companies
only need the report number, not a copy of the report. You may want to check with each company.
Signature
I declare under penalty of perjury that the information I have provided in this affidavit is true and
correct to the best of my knowledge.
_______________________________________ __________________________________
(signature) (date signed)
Knowingly submitting false information on this form could subject you to criminal
prosecution for perjury.
______________________________________
(Notary)
[Check with each company. Creditors sometimes require notarization. If they do not, please have one
witness (non-relative) sign below that you completed and signed this affidavit.]
Witness:
_______________________________________ __________________________________
(signature) (printed name)
_______________________________________ __________________________________
(date) (telephone number)
Name __________________________________ Phone number _______________________ Page 4
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Florida's Identity Theft Victim Kit PDF

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