CED-13 (5/2017)
ID THEFT COMPLAINT FORM
Use this form to report identity theft to the Department of Motor Vehicles. You should also contact your local law
enforcement agency to file a police report. For more information regarding identity theft, please visit the Nevada Identity
Theft Program on the Attorney General’s website at: http://ag.nv.gov/Hot_Topics/Victims/IDTheft/
1. Full legal name:
(First) (Middle) (Last) (Jr., Sr., III)
2. Date of birth: 4. Social Security Number:
(month / day / year)
3. Driver’s License or ID card number: State
4. Current address:
City State Zip Code
5. Telephone numbers: Daytime: Evening: Cell:
Check all items that apply:
6. I did not authorize anyone to use my name or personal information to obtain any DMV license, registration or service.
7. My identification documents (i.e. birth certificate, Social Security card, driver’s license) were:
stolen lost on or about neither (describe at # 9)
(month / day / year)
8. I do NOT know who used my information or identification documents to get DMV services in my name without my
knowledge or authorization. If you DO know who used your documents, please provide that information below.
9. Additional Comments: Please describe the fraud which has occurred listing which documents or information were used
and describe how the identity thief gained access to your information (if known). Use back of document if needed.
I certify that, to the best of my knowledge and belief, all the information on and attached to this affidavit is true, correct, and
complete and made in good faith. I also understand that this affidavit or the information it contains may be made available to
federal, state, and/or local law enforcement agencies for such action within their jurisdiction as they deem appropriate.
Signatures must be original. Photocopies are not acceptable
.
(Signatur
e) (Date)
(Notar
y or DMV Representative) (Date)
Compliance Enforcement Division
555 WRIGHT WAY
Carson City, Nevada 89711-0250
(775) 684-4690
dmvnv.com
