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IDENTITY THEFT COMPLAINT FORM

Office of the Indiana Attorney General

= Required Information

1. Complainant Information

Are you with an agency or organization and filing on behalf of another individual?	(loading...)
Salutation
First Name
Middle Name
LastName
Address
City
State	(loading...)

Zip
Daytime Phone
Evening Phone
Email
Driver’s License Number
Expiration Date	[ 4/24/2024 ]
Date of Birth (mm/dd/yyyy)
Social Security Number (SSN)
You may refuse to provide your SSN and will not be penalized. However, disclosing your SSN will assist our Office in investigating your complaint and working with law enforcement. If you do provide your SSN, by signing this form you expressly consent to the disclosure of your SSN for investigative purposes in accordance with Indiana Code § 4-1-10-5(2).

2. Financial Institution Information

Have you contacted your financial Institution(s) to report the alleged ID Theft?

Yes

If yes, which financial institutions have you contacted?

Has your financial institution refunded your money for the fraudulent purchases?

Yes

3. Law Enforcement Information

Have you filed a police report?

Yes

If yes:

Date filed

[ 4/24/2024 ]

Police Department

Report Number

4. Crime details

What date did you first become aware of the crime?	[ 4/24/2024 ]
How did you become aware of the identity crime?
	Found fraudulent transactions on my credit card. Which one(s)?
	Contacted by creditor or received bills for account I did not open. Which one(s)?
	Denied credit or a loan. Where?
	Was arrested, had a warrant or complaint filed in my name and I was not aware if it.
	IRS notice or message that someone else used my SSN.
	Was denied employment. Where?
	Contacted by creditor demanding payment on debt that is not mine. Which one(s)?
	Irregularities on my credit report
	Other:


If applicable, please complete the information below to assist in reviewing your complaint.
ACCOUNTS AFFECTED BY CRIME

1. Company or Organization Name	(Deleting...)
Date Fraud Began
Date Fraud was Discovered
Total Amount of Fraud
Fraudulent Account Number

	(Adding...)

5. Identity Theft Complaint Summary Please provide a summary of your identity theft complaint. Please list all fraudulent activity that you are aware of and the dates, times, locations and addresses where fraudulent applications or purchases were made (retailers, banks, etc.) List events in chronological order, if possible. Please be concise and state the facts. You may attach a separate sheet if additional space is needed.

Identity Theft Complaint Summary

6. Credit Report Information

Have you requested a credit report from each of the three credit reporting agencies

Yes

If yes, please check all that you have requested a report from:

Equifax

Experian

TransUnion

Please upload complete copies of the reports per the instructions at the bottom of this page.Please attach complete copies of the reports to this form. A credit report will assist you in determining how many fraudulent accounts may have been opened using your information. It will also improve our ability to investigate your case. You can order your free credit report by calling 1-877-322-8228 or going to www.annualcreditreport.com

7. Consent

Do you consent to disclosing the following information to the public?

The fact that you filed this complaint

Yes

Your name

Yes

Your phone number

Yes

8. Consent and Verification

I affirm, under the penalties for perjury, that the foregoing representations, and those in all attachments that were prepared by me, are true. The information I have provided in this complaint form is based upon my personal knowledge. I consent to the release of any relevant information to the Identity Theft Unit. If I do provide my Social Security Number, I expressly consent to the disclosure of my Social Security Number in accordance with Indiana Code § 4-1-10-5(2). By filing this complaint, I understand that the Attorney General is not my private attorney, but enforces state consumer protection laws. I also agree to assist in the investigation and understand that I may be called to testify in court to the facts stated in this complaint.
Your Name
Date	[ 4/24/2024 ]

9. Consent to correspondence by Email

Do you consent to the Consumer Protection Division sending you correspondence related to this complaint to your email address? If yes, you will not be mailed such correspondence via the U.S. Postal Service. If you select Yes please enter the email address we should use to send correspondence even if it is the same as the email address you entered earlier.
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If you have supporting documentation or materials related to this complaint that you would like to upload at this time, please check the box below. After you click the Submit button below you will be directed to another page where you can upload those files.

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