Full Text
CIS-010 (04/01/05) MICHIGAN STATE POLICE AFFIDAVIT OF FRAUD AND FORGERY Last Name First Name Middle Name Social Security Number Date of Birth Driver License Number Daytime Telephone Evening Telephone Current Street Address City State Zip Code Address Where Events Took Place If Different Than Above City State Zip Code I did not authorize anyone to use my name or personal information to seek money, credit, loans, goods or services. I did not receive any benefits, money, goods or services as a result of the events described in this report. I am willing to assist in the prosecution of the person(s) who committed this fraud. I authorize the release of credit and/or other information to law enforcement for the purpose of assisting them in the investigation and prosecution of the person(s) who committed this fraud. 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. Complainant Signature Date Witness Signature Date Witness Printed Name Subscribed and sworn before me on the Day day of Month Year Notary Signature Notary Public in and for the county of County Michigan My commission expires on Date THIS INFORMATION IS CONFIDENTIAL. DISCLOSURE OF CONFIDENTIAL INFORMATION IS PROTECTED BY THE FEDERAL PRIVACY ACT. AUTHORITY: 1935 PA 59, as amended COMPLIANCE: Voluntary