Www.texasbar.com
IDENTITY THEFT QUESTIONNAIRE
Name: _________________________________________________________________________
Address: _______________________________________________________________________
City/State/ZIP: ___________________________________________________________________
Phone: _________________________ Alternate Phone: _________________________
Why do you think you are the victim of Identity Theft? ____________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
When did you first notice this problem? ________________________________________________
_______________________________________________________________________________
Have you reported this problem to the police or law enforcement? Y N
If yes, when? __________________ Do you have a copy of that report? Y N
Have you reported this problem to the credit reporting agencies? Y N
Are creditors after you to repay any debts that you did not incur? Y N
Number of credit cards or consumer accounts that may be affected: _________________________
How many addresses have you used in the past three years? ______________________________
Have you completed Postal Change of Address forms when you moved each time? Y N
Did you have a problem with your mail at any of these addresses? Y N
If yes, please explain: _____________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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
(over)
What do you want to do about your current identity theft situation?
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
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