Florida's Identity Theft Victim Kit

ID Theft Affidavit
Name __________________________________ Phone number _______________________ Page 1
Victim Information
(1) My full legal name is ___________________________________________________________
(First) (Middle) (Last) (Jr., Sr., III)
(2) (If different from above) When the events described in this affidavit took place, I was known as
____________________________________________________________________________
(First) (Middle) (Last) (Jr., Sr., III)
(3) My date of birth is ____________________
(day/month/year)
(4) My social security number is________________________________
(5) My driver’s license or identification card state and number are__________________________
(6) My current address is __________________________________________________________
City ___________________________ State _________________ Zip Code ______________
(7) I have lived at this address since _____________________________
(month/year)
(8) (If different from above) When the events described in this affidavit took place, my address
was_________________________________________________________________________
City ___________________________ State _________________ Zip Code ______________
(9) I lived at the address in #8 from __________ until __________
(month/year) (month/year)
(10) My daytime telephone number is (____)____________________
My evening telephone number is (____)____________________
Page 7/12
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Florida's Identity Theft Victim Kit PDF

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