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State of Montana Department of Justice Identity Theft Passport Application Personal Information Name Last First Middle Prior Names or Aliases Last First Middle Mailing Address Street or PO Box City State Zip Previous Address Street or PO Box City State Zip Home Phone ( ) Date of Birth Work Phone ( ) Place of Birth U.S. Citizen Yes No Gender Female Male *Social Security # - - **Driver's License State Number *Disclosure is voluntary & for identification purposes only Copy of Driver's License must be included Crime Information Date you discovered the theft County & State where theft occurred Law enforcement agency crime reported to Case # Has the person who stole your information been identified? Yes No If yes, please provide name of the suspect Suspect’s Name Has the suspect been arrested? Yes No Unknown Type of Theft (credit card, checks, ATM, SSN, etc.) Account Numbers Approximate Amount $ $ $ $ Use additional paper if necessary Continued on Next Page August 2007 Page 1 of 2 ---PAGE BREAK--- August 2007 Page 2 of 2 Please provide a brief description of Identity Theft Incident Use additional paper if necessary Applicant Certification I understand that if I knowingly provide false information, I may be subject to false swearing charges under Montana law (45-7-202, MCA). By signing this application, I attest that: • the information provided on this form is true and accurate, and • I have filed a true and accurate police report of this incident. Applicant Signature Date Law Enforcement Certification Law Enforcement Officer (Print Name) Law Enforcement Officer (Signature) Law Enforcement Agency and Phone Please send or fax this form to: Department of Justice – ID Theft Passport PO Box 200151 Helena, MT 59620 Fax: (406) 444-9680 Phone: (406) 444-4500