I thought others here might find this form of interest. This is the form that is talked about above. Note the questions carefully
Cut and Paste Follows
Instructions for Completing the Fraudulent Transaction Form
To make certain that you do not become responsible for the debts incurred by the fraudulent transactions you must complete the following form. You can use this form where a new account was opened in your name. The information will enable the companies to investigate the fraud and decide the outcome of your claim.
Be as accurate and complete as possible.
-Please print clearly.
-When you have finished completing the affidavit, either fax or mail a copy back to the following coordinates..
Fax: XXXXXXXXXXXX
Address:
XXXXXXXXXXXXXXXX
Suite XXX
Montreal, Quebec, Canada
XXXXXXXXXXXX
Fraudulent Transaction Form
(1) My full legal name is ___________________________________________________________
(First) (Middle) (Last) (Jr., Sr., III)
(2) (If different from above) When the events described in this affidavit took place, I was known as
______________________________________________________________________
(First) (Middle) (Last) (Jr., Sr., III)
(3) My date of birth is ____________________
(day/month/year)
(4) My current address is: __________________________________________________________
City ___________________________ State/Province _________________
Zip/Postal Code ______________
(5) I have lived at this address since _____________________________
(month/year)
(6) (If different from above) When the events described in this affidavit took place, my address was: __________________________________________________________________
City ___________________________ State/Province _________________
Zip/Postal Code ______________
(7) My daytime telephone number is (____)____________________
My evening telephone number is (____)____________________
How the Fraud Occurred
Check all that apply for items 8 - 12:
(

❑I did not authorize anyone to use my name or personal information to complete the transactions described in this report.
(9) ❑My identification documents (for example, credit cards; e-mail address; etc.) were stolen on or about ____________________.
(day/month/year)
______________________________________________________________________
Credit Card Number and Security Code (on back of card)
(10) ❑To the best of my knowledge and belief, the following person(s) used my information and credit card to complete the transactions described in this report.
______________________________________________________________________
Name (if known) Name (if known)
______________________________________________________________________
Address (if known) Address (if known)
______________________________________________________________________Phone number(s) (if known) Phone number(s) (if known)
_________________________________ ____________________________________
E-mail account (if known)
(11) ❑ I do NOT know who used my credit card to complete the transactions described in this report.
(12) ❑Additional comments (if any)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Attach additional pages as necessary.)
Victim’s Law Enforcement Actions
(13)(check one) I ❑ (am) ❑ (am not) authorizing the release of this information to law enforcement for the purpose of assisting them in the investigation and prosecution of the person(s) who committed this fraud.
(14)(check all that apply) I ❑ have ❑ have not reported the events described in this affidavit to the police or other law enforcement agency. The police ❑ did ❑ did not write a report.
In the event you have contacted the police or other law enforcement agency, please complete the following:
_____________________________ _________________________________
(Agency #1) (Officer/Agency personnel taking report)
____________________________ _________________________________
(Date of report) (Report Number, if any)
_____________________________ _________________________________
(Phone number) (e-mail address, if any)
_____________________________ _________________________________
(Agency #2) (Officer/Agency personnel taking report)
_____________________________ _________________________________
(Date of report) (Report Number, if any)
_____________________________ _________________________________
(Phone number) (e-mail address, if any)
I,______________________ declare under penalty of perjury that the information I have provided in this document is true and correct to the best of my knowledge. As a result of the event(s) described in the Transaction List (below), the following accounts was/were opened in my name without my knowledge, permission or authorization using my personal information or identifying documents.
__________________________________
(Signature)
__________________________________
(Date)
Knowingly submitting false information on this form could subject you to criminal
prosecution for perjury.
Disputed Transaction/s:
#1
Transaction as appears on Credit Card Statement:
Website Joined:
User Name Used:
E-mail Address Used:
IP Address from which transaction originated:
Name On Credit Card Used:
Credit Card Number Used: xxxx-xxxx-xxxx-
#2
Transaction as appears on Credit Card Statement:
Website Joined:
User Name Used:
E-mail Address Used:
IP Address from which transaction originated:
Name On Credit Card Used:
Credit Card Number Used: xxxx-xxxx-xxxx-