IDENTITY THEFT QUESTIONNAIRE



	(Do NOT complete and return if another state or federal prosecutor has filed criminal charges as a result of your allegation. ) 



1.	Current name and address:



	____________________________________

	(Name)

	____________________________________

	(Address)

	____________________________________

	(Phone number)



2.	Name and address at the time you became an Identity Theft Victim:



	____________________________________

	(Name)

	____________________________________

	(Address)

	____________________________________

	(Phone number)



3.	How did you learn about the theft of your identity?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



4.	What facts support your allegation that someone stole your identity?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



5.	What documentation supports the allegation that someone stole your identity?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



6.	If some other individual or entity possesses any of the documentation noted in your answer to Question No. 5, please provide the name and contact information for each individual, business, or organization.

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



7.	Did you and/or someone else lose money because of the identity theft?  If so, who lost money and how much did they lose?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



8.	Have you filed forgery affidavits or other documents with banks, credit card companies or others which allege that someone other than you is responsible for generating charges or securing accounts in your name?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



9.	Have you reported the allegation regarding the theft of your identity to a state, local, or federal law enforcement agency other than the Federal Trade Commission?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



10.	If you answered "yes" to Question No. 9, to whom did you report it and when did you report it?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



11.	Do you know who committed the identity theft?  

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



12.	If you answered "yes" to Question No. 11, please give the name, address, phone number, and other identifying information on the individual(s). 

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



13.	What is/was your relationship, if any, to the person who you have identified as the perpetrator in your response to Question No. 12?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



14.	If the person identified in your response to Question No. 12 is a former spouse, was your divorce final at the time of the theft of your identify?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



15.	What is the basis of your knowledge that the individual(s) listed in your response to Question No. 12 is responsible for the theft of your identity?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________

16.	Has the person(s) named in your response to Question No. 12 admitted to you or anyone else that he/she/they is/are responsible for the theft of your identity?  If so, please explain when this occurred and to whom it was communicated?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



17.	If you responded "yes" to Question No. 12, has the person identified ever been convicted of a crime?  If so, what crime?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



18.	Was your Social Security Number misused by the person identified in your response to Question No. 12 as part of the theft of your identity?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



19.	If you responded "yes" to Question No. 18, what is the basis for your response?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



20.	If you were not living in Montana at the time of the identity theft, was the individual responsible for the theft of your identity in Montana?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________



21.	If you answered "yes" in response to Question No. 20, what is the basis for your belief?

	________________________________________________________________

	________________________________________________________________

	________________________________________________________________





Please provide copies of all written documentation regarding your allegation, including but not limited to, bank statements noting fraudulent transactions, credit card statements noting fraudulent transactions, account applications with forged signatures or misused social security numbers, written admissions of theft of your identity by the perpetrator, forgery affidavits submitted by you to banks and/or credit card companies and mail this form and all supporting documentation to:



William Mercer

U.S. Attorney

P.O. Box 1478

Billings, MT 59103