Fraud Affidavit Form

INSTRUCTIONS: This is a voluntary form for filing a report of identity theft with the New Mexico Department of Workforce Solutions (NMDWS). Fill out all sections below to the best of your ability.

About You (the victim)

First Name:

Middle Initial:

Last Name:

Date of Birth:

Social Secuirty Number (SSN):

Drivers License Number:

Issued by State:

Address Information

Current Street Name:

Apartment, Suite, etc.:

City:

State:

Zip:

I have lived at this address since (mm/yyyy):

Phone:

Email:

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