Florida's Identity Theft Victim Kit

I declare (check all that apply):
As a result of the event(s) described in the ID Theft Affidavit, the following account(s) was/were
opened at your company in my name without my knowledge, permission or authorization using my
personal information or identifying documents:
Completing this Statement
Make as many copies of this page as you need. Complete a separate page for each
company you’re notifying and only send it to that company. Include a copy of your
signed affidavit.
List only the account(s) you’re disputing with the company receiving this form. See the
example below.
If a collection agency sent you a statement, letter or notice about the fraudulent account,
attach a copy of that document (NOT the original).
Fraudulent Account Statement
Creditor Name/Address
(the company that opened the
account or provided the goods or
services)
Account
Number
Type of unauthorized
credit/goods/services
provided by creditor
(if known)
Date
issued or
opened (if
known)
Amount/Value
provided
(the amount
charged or the
cost of the
goods/services)
During the time of the accounts described above, I had the following account open with your company:
Billing name ________________________________________________________________________
Billing address ______________________________________________________________________
Account number ____________________________________________________________________
Example
Example National Bank
22 Main Street
Columbus, Ohio 22722
01234567-89 auto loan 01/05/2000 $25,500.00
Name __________________________________ Phone number _______________________ Page 5
Page 11/12
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Florida's Identity Theft Victim Kit PDF

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