Identity Theft Complaint Form

* Salutation:
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* First Name:
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Middle Initial:
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* Last Name:
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* Email Address:
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A copy of this form will be sent to the email address provided.

* Phone Number:
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* Mailing Address:
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* City:
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* State:
Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming State is required

* Zip Code:
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1. How did you first become aware that your identity has been compromised? Please list specific details about the date and time that you have been made aware of any data compromises.
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2. Do you know who may have used your information without authorization? If so, please provide as many details as you have below:
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3. What information specifically do you believe has been compromised?
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(Credit card, social security number, etc.)

4. What has happened as a result of your information being compromised?
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(Money lost, credit report inaccurate, etc. )

5. Have you contacted your banking institution or credit card company?

Yes

No

6. Has the compromised account been closed?

Yes

No

7. Have you already filed a complaint with the local Law Enforcement Agency?

Yes

No

Name of Law Enforcement Agency:
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Report/Case Number:
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8. Have you reviewed your credit report to check for inaccuracies?

Yes

No

9. Have you placed a fraud alert or credit freeze on your credit report?

Yes

No

10. Have you filed a report with the Federal Trade Commission?

Yes

No

11. If this theft is tax-related, have you filed a report with the Internal Revenue Service?

Yes

No

Not tax-related

12. Who else have you contacted about this concern?
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13. Will you willingly testify in a hearing before the Attorney General or designee should formal disciplinary proceedings be initiated?

Yes

No

If you answered no above, please explain:
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In filing this request, I understand and agree that the Attorney General and the Attorney General's Office staff are not my private attorneys, but instead represent the State of Kansas in enforcing laws designed to protect the public from deceptive and unconscionable business acts and practices. I understand that Kansas Law limits the period of time during which I may file any private legal action(s). I further understand and agree that the contents of this request may be forwarded to the business or person the request is directed against, may be forwarded to other appropriate agencies, and will become accessible to others under the Kansas Open Records Act. I hereby authorize any party to whom the Attorney General directs this complaint to release any and all information about this matter, including account information, to the Kansas Attorney General's Office. Finally, I declare and verify under penalty of perjury and the laws of Kansas that all of the foregoing is true and accurate to the best of my knowledge.

* Please certify your agreement to the above statement by typing your full name in the box below:
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