How the Fraud Occurred
I did not authorize anyone to use my name or personal information to seek the money, credit, loans, goods or services described in this report.
To the best of my knowledge and belief, the following person(s) used my information (for example, my name, address, date of birth, existing account numbers, social security number, mother's maiden name, etc.) or identification documents to get money, credit, loans, goods or services with my knowledge or authorization:
Name: Nicole Shanahan Brin
Address: Los Altos Hills California
Name: Sergey M.Brin
Address: Los Altos Hills California
Name: Google
Address: Mountain View California
my identity theft affadavit from rocket lawyer.
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ID Theft Affidavit
Victim Information
My full legal name is Kimberly Marie LaPointe.
My date of birth is January 10, 1971.
My social security number is - -
My driver's license or identification card state and number is _________________.
My current address is 219 School St, Chicopee, MA 01013. I have lived at this address since MARCH 1,2013.
My daytime telephone number is 14132188147.
My evening telephone number is 14132188147.
How the Fraud Occurred
I did not authorize anyone to use my name or personal information to seek the money, credit, loans, goods or services described in this report.
My current address is 219 School St, Chicopee, MA 01013. I have lived at this address since MARCH 1,2013.
My daytime telephone number is 14132188147.
My evening telephone number is 14132188147.
How the Fraud Occurred
I did not authorize anyone to use my name or personal information to seek the money, credit, loans, goods or services described in this report.
To the best of my knowledge and belief, the following person(s) used my information (for example, my name, address, date of birth, existing account numbers, social security number, mother's maiden name, etc.) or identification documents to get money, credit, loans, goods or services with my knowledge or authorization:
Name: Nicole Shanahan Brin
Address: Los Altos California
Name: Sergey M.Brin
Address: Los Altos Hills California
Name: Google
Address: Mountain View California
Victim's Law Enforcement Actions
I am willing to assist in the prosecution of the person(s) who committed this fraud.
I am 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.
I have reported the events described in this affidavit to the police or other law enforcement agency. The police did not write a report.
Supporting Documentation
I am providing the following supporting documentation:
As proof of my identification, I am attaching a copy of A Real ID
As proof of my residency during the time the fraud occurred, I am attaching a copy of A Landlord Signed Paper&Utility Bill etc.
Signature
I declare under penalty of perjury that the information I have provided in this affidavit is true and correct to the best of my knowledge.
| ______________________________ | ____________________________ |
| Kimberly Marie LaPointe | (Date signed) |
Knowingly submitting false information on this form could subject you to criminal prosecution for perjury.
Subscribed and sworn to (or affirmed) before me this ____ day of ____________________, ______.
______________________________
Signature
I declare under penalty of perjury that the information I have provided in this affidavit is true and correct to the best of my knowledge.
| ______________________________ | ____________________________ |
| Kimberly Marie LaPointe | (Date signed) |
Knowingly submitting false information on this form could subject you to criminal prosecution for perjury.
Subscribed and sworn to (or affirmed) before me this ____ day of ____________________, ______.
______________________________
Signature - Notary Public
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