Identity Theft Contact Form

Name

Email Address

Phone Number

Address

City

State

Zip

Do you suspect that someone has used your personal information (Social Security number, drivers license number, account numbers, date of birth, employer or taxpayer ID number, passport number etc.) for unauthorized or fraudulent activity?
Yes No

Please describe briefly the relevant facts.

Do you know the identity of any person(s) who may be involved?

Please list any merchants or financial institutions with which the identity thief may have dealt fraudulently.

Please list any police departments or other law enforcement agencies with which you have filed complaints.

Have you filed an identity theft report with the Federal Trade Commission (FTC)?
Yes No
If so, when?

Have you reported the identity theft to any credit bureau?
Yes No
If so, please provide details.

Do you suspect the identity thief may have committed other fraud in your name, such as entering into leases, contracts, or mortgages; obtaining employment; or posing as you in the commission of other crimes?
Yes No
If so, please provide details.

How much personal time have you used trying to discover and solve this identity theft problem?
hours

How much money do you estimate you have spent trying to discover and solve this identity theft problem?
$

Has your credit rating or reputation been harmed?

Has the theft of your identity caused you mental, emotional, or physical problems (such as anxiety, fear, paranoia, anger, fatigue, insomnia, physical manifestations of anxiety, or exacerbation of previous illness)?
Yes No

If so, please elaborate.

Please provide any other relevant details.

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