Office of the Indiana Attorney General
2. Financial Institution Information
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3. Law Enforcement Information
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.
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6. Credit Report Information
7. Consent
Do you consent to disclosing the following information to the public? |
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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. |
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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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