<p> IDENTITY THEFT QUESTIONNAIRE</p><p>Name: ______</p><p>Address: ______</p><p>City/State/ZIP: ______</p><p>Phone: ______Alternate Phone: ______</p><p>Why do you think you are the victim of Identity Theft? ______</p><p>______</p><p>______</p><p>______</p><p>When did you first notice this problem? ______</p><p>______</p><p>Have you reported this problem to the police or law enforcement? Y N</p><p>If yes, when? ______Do you have a copy of that report? Y N</p><p>Have you reported this problem to the credit reporting agencies? Y N</p><p>Are creditors after you to repay any debts that you did not incur? Y N</p><p>Number of credit cards or consumer accounts that may be affected: ______</p><p>How many addresses have you used in the past three years? ______</p><p>Have you completed Postal Change of Address forms when you moved each time? Y N</p><p>Did you have a problem with your mail at any of these addresses? Y N</p><p>If yes, please explain: ______</p><p>______</p><p>______</p><p>______</p><p>Do you know, or have a good suspicion of, who may be using your personal information or making unauthorized purchases in your name? Y N</p><p>(over) What do you want to do about your current identity theft situation? </p><p>File a police report with the county sheriff’s department? Y N File a report with the police department? Y N File charges against a specific individual for identity theft? Y N File a notice to the credit reporting agencies? Y N Request a referral to a local nonprofit consumer counseling agency with the goal of clearing your negative credit history? Y N Request a credit freeze so that no one can view your credit files? Y N Stop creditors from harassing you by telephone? Y N Have an attorney represent you to contest debts that you did not lawfully incur? Y N I have proof that these debts are not mine. Y N</p>