Florida's Identity Theft Victim Kit

How the Fraud Occurred
Check all that apply for items 11 - 17:
(11)
I did not authorize anyone to use my name or personal information to seek the money,
credit, loans, goods or services described in this report.
(12)
I did not receive any benefit, money, goods or services as a result of the events described
in this report.
(13) My identification documents (for example, credit cards; birth certificate; driver’s license;
social security card; etc.) were stolen
lost
on or about ____________________.
(day/month/year)
(14) To the best of my knowledge and belief, the following person(s) used my information (for
example, my name, address, date of birth, existing account numbers, social security number, mother’s
maiden name, etc.) or identification documents to get money, credit, loans, goods or services without
my knowledge or authorization:
_________________________________ _____________________________________
Name (if known) Name (if known)
_________________________________ _____________________________________
Address (if known) Address (if known)
_________________________________ _____________________________________
Phone number(s) (if known) Phone number(s) (if known)
_________________________________ ____________________________________
additional information (if known) additional information (if known)
_________________________________ _____________________________________
_________________________________ _____________________________________
(15) I do NOT know who used my information or identification documents to get money,
credit, loans, goods or services without my knowledge or authorization.
(16)
Additional comments: (For example, description of the fraud, which documents or
information were used or how the identity thief gained access to your information.)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
(Attach additional pages as necessary.)
Name __________________________________ Phone number _______________________ Page 2
Page 8/12
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Florida's Identity Theft Victim Kit PDF

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