Fraud / Identity Theft Report Form
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Contact the local police department where the crash occurred
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Name
*
First Name
Last Name
Alias/Maiden Names
Drivers License or ID #
*
State issued in
*
Date of birth
*
-
Month
-
Day
Year
Date
Social Security #
*
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email address
example@example.com
Total amount of financial loss($)
*
Have you been reimbursed for the amount listed above?
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YES
NO
Partially
If partially reimbursed, how much?
How did you become aware of the crime?
*
Fraudulent charges on credit card bill
Fraudulent charges on my cellular phone bill
Your cellular phone number & service provider
Received bills for an account(s) I did not open
Found irregularities on my credit report
Was contacted by a creditor demanding payment for something I did not buy
Was contacted by a bank's fraud department about charges
Other
Please explain your selection above. (Names, dates, account #'s, etc)
What date did you first become aware of the crime
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Month
-
Day
Year
Date
When did the fraudulent activity begin
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Month
-
Day
Year
Date
Was the fraudulent activity made using your name
*
YES
NO
UNKNOWN
If you answered "NO" above, please list full name, address, and any other identifying information that the fraudulent activity was made under.
Please indicate if personal or business
To the best of your knowledge at this point, what identity crimes have been committed? (Check all that apply)
Opening a new credit card account in my name
Unauthorized withdrawals from my bank account
Taking out unauthorized loans in my name
Check fraud
Opening utility and/or telephone account(s) in my name
Unauthorized access to my securities or investment accounts
Credit card purchase(s) without my authorization
Passport/visa fraud
Opening new bank accounts in my name
Obtaining government benefits in my name
Obtaining employment in my name
evading prosecution for crimes committed by using my name or committing new crimes under my name
Other
Suspect Information
Check if suspect information is unknown
Suspect's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Suspect's Date of birth
-
Month
-
Day
Year
Date
Suspect's Phone Number
Please enter a valid phone number.
Please list your relationship with the suspect and why you feel they committed the fraud you are reporting
Please list any government documents fraudulently obtained in your in your name (Driver's license, SSN, etc.)
Have you contacted any of these organizations and requested a "Fraud Alert" be put on your account?
Your bank/credit union(s)
Equifax www.equifax.com
TransUnion www.transunion.com
Experian www.experian.com
Social Security Administration
Other
Please add details for selections above (Dates, Account #s, contact person, etc)
Have you been the victim of any other crime that could be related? (i.e. theft or loss of wallet) Please provide
List ALL fraudulent activity that you are aware of to date. Include locations and address of where fraudulent applications or purchases were made. Please be concise
Please provide information for each account that your are reporting had fraudulent/theft activity.
Please provide any documentation you have that will help with the investigation.
Browse Files
Drag and drop files here
Choose a file
Account statements, bills, emails,
Cancel
of
By filing this complaint, I understand that:
A person commits a crime of making a false report if they willfully make any untrue, misleading, or exaggerated statement in any report to a police department
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YES
Making a false report is an offense in violation of N.J.S.A. 2C:28-4b.
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YES
I certify under penalty of perjury under the laws of the State of New Jersey that the foregoing is true and correct
Name
*
First Name
Last Name
Date signed
*
-
Month
-
Day
Year
Date
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