
5. I do not know who used my information or identification documents to get money, credit, loans, goods or services
without my knowledge or authorization.
6. Additional comments (For example, description of the fraud, which documents or information were used or how the
identity thief gained access to your information.)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________ (Attach additional pages as necessary.)
Name Address (if known)
Phone Number(s) Additional Information
Name Address (if known)
Phone Number(s) Additional Information
NAME (IF DIFFERENT FROM ABOVE) WHEN THE EVENTS DESCRIBED IN THIS AFFIDAVIT TOOK PLACE
CURRENT ADDRESS
Check all that apply for items 1-6:
1. 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.
2. I did not receive any benefit, money, goods or services as a result of the events described in this report.
3. My identification documents (for example, credit cards, birth certificate, driver's license, Social Security card, etc.) were
stolen lost on or about _______________________________________________________ (month/day/year)
4. 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 without my knowledge or authorization:
DR 2153 (11/13/07)
COLORADO DEPARTMENT OF REVENUE
DIVISION OF MOTOR VEHICLES
INVESTIGATIONS UNIT
1881 PIERCE STREET, ROOM 136
LAKEWOOD, COLORADO 80214
(303) 205-8383
AFFIDAVIT OF
COLORADO DRIVER'S LICENSE
OR ID THEFT
Take (DO NOT MAIL OR FAX) this completed, notarized form
with a police report to a driver’s license office to apply for a license or ID with a new number (PIN).
VICTIM IDENTIFICATION
Note: Knowingly submitting false information on this form could subject you to criminal prosecution for perjury.
First Middle Last
Jr.
Sr.
III
FULL LEGAL NAME
Date of Birth Social Security Number Driver's license or Identification card number (PIN)
Address City
State ZIP Code Beginning date of residence at this address:
Month Year
First Middle Last
Jr.
Sr.
III
Address City
State ZIP Code Beginning and End date of residence at this address:
From: To:
HOW THE FRAUD OCCURRED
Current Daytime Telephone Number Current Evening Telephone Number
ADDRESS (IF DIFFERENT FROM ABOVE) WHEN THE EVENTS DESCRIBED IN THIS AFFIDAVIT TOOK PLACE
Month Year
Month Year