As applicable, sign and date in a presence of a law enforcement officer, a notary, or a witness.
I certify that, to the best of my knowledge and belief, all of the information on and
attached to this complaint is true, correct, and complete and made in good faith. I
understand that this complaint or the information it contains may be made available to
federal, state, and/or local law enforcement agencies for such action within their
jurisdiction as they deem appropriate. I understand that knowingly making any false or
fraudulent statement or representation to the government may violate federal, state, or
local criminal statutes, and may result in a fine, imprisonment, or both.
If you do not choose to file a report with law enforcement, you may use this form as an
Identity Theft Affidavit to prove to each of the companies where the thief misused your
information that you are not responsible for the fraud. While many companies accept this
affidavit, others require that you submit different forms. Check with each company to see
if it accepts this form. You should also check to see if it requires notarization. If so, sign
in the presence of a notary. If it does not, please have one witness (non-relative) sign that
you completed and signed this Affidavit.