The Colorado DR 2153 form is an affidavit specifically designed for individuals who have experienced driver's license or identification theft. This important document allows victims to report the theft and apply for a new license or ID number. By submitting this notarized form along with a police report, victims can take significant steps toward reclaiming their identity and protecting themselves from further fraud.
The Colorado DR 2153 form serves as a crucial document for individuals who have experienced identity theft related to their driver's license or state-issued identification. This affidavit must be completed and notarized before being submitted to a local driver's license office, accompanied by a police report. The form requires the victim to provide personal information, including their full legal name, date of birth, and Social Security number, as well as details about the fraudulent activities that occurred. It is essential for the victim to identify how the fraud happened, whether through unauthorized use of their personal information or theft of identification documents. Additionally, the form includes sections where the victim can specify any law enforcement actions taken, such as filing a police report. By signing the affidavit, the victim not only affirms the accuracy of the information provided but also expresses their willingness to assist in the prosecution of the perpetrator. This process is designed to help victims regain control over their identities and obtain a new driver's license or ID number, ensuring they can move forward after experiencing such a distressing event.
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.
FULL LEGAL NAME
First
Middle
Last
Jr. Sr. III
NAME (IF DIFFERENT FROM ABOVE) WHEN THE EVENTS DESCRIBED IN THIS AFFIDAVIT TOOK PLACE
Jr.
Sr.
III
Date of Birth
Social Security Number
Driver's license or Identification card number (PIN)
CURRENT ADDRESS
Address
State
City
ZIP Code
Beginning date of residence at this address:
Month
Year
ADDRESS (IF DIFFERENT FROM ABOVE) WHEN THE EVENTS DESCRIBED IN THISAFFIDAVIT TOOK PLACE
Beginning and End date of residence at this address:
From:
To:
Current Daytime Telephone Number
Current Evening Telephone Number
HOW THE FRAUD OCCURRED
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.
I did not receive any benefit, money, goods or services as a result of the events described in this report.
2.
My identification documents (for example, credit cards, birth certificate, driver's license, Social Security card, etc.) were
3.
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:
Name
Address (if known)
Phone Number(s)
Additional Information
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.)
VICTIM’S LAW ENFORCEMENTACTIONS
7.My signature below indicates that I am willing to assist in the prosecution of the person(s) who committed this fraud.
8.My signature below authorizes the release of this information to law enforcement for the purpose of assisting them in the investigation and prosecution of the persons who committed this fraud.
9.(check all that apply) I have reported the events described in this affidavit to the police or other law enforcement
agency. The police
did
did not write a report. Please complete the following:
Agency Number 1
Officer/Agency personnel taking report
Date of report
Report number, if any
Phone number
E-mail address, if any
Agency Number 2
Please indicate the supporting documentation you are able to provide.Attach copies (NOT originals) to the affidavit. Acopy of the report filed with the police or sheriff’s department is attached.
SIGNATURE
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. I understand that if I give a false statement, my driver's license or identification card may be canceled and denied, in accordance with § 42-2-122, C.R.S. I also understand that if I am convicted of perjury in the first or second degree, the Department shall immediately revoke my driver's license or identification card, in accordance with § 42-2-125, C.R.S.
Knowingly submitting false information on this form could subject you to criminal prosecution for perjury.
Signature__________________________________________________Date signed _____________________________
Subscribed and sworn to before me in the County of _________________________________________, State of Colorado,
this_______________________________________ day of ________________________________, 2 ______________
Notary Public________________________________________________ My commission expires ___________________
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