Previous name or maiden name (if applicable):

_____________________________________________________________

Current address: (include zip code)

_____________________________________________________________

Former address (for those who have moved in last 5 years):

1)____________________________________________________________

2)____________________________________________________________

Date of Birth_____________________________(xx-xx-xxxx)

SS#____________________________________

Drivers’ License State and Number__________________________________

One piece of ID is included which verifies my address:

(copy of driver’s license, government issued ID, water bill, electric bill)

Method of payment*

Personal check enclosed___________ Money Order enclosed___________

Credit card #______________________Type of card: (Visa, Mastercard, Discover)

Name on card___________________________________________________

Expiration date_____________________

Card ID (three-digit security number on back of card)_________

*IF CLAIMING ID THEFT AND FREE FREEZE, INCLUDE INFORMATION

INCLUDING ID THEFT AFFADAVIT, POLICE REPORT,DMV REPORT)

MY SIGNATURE:

________________________________________Today’s date_____________

Mailing Addresses:

Equifax Security Freeze

P.O. Box 105788

Atlanta, GA 30348

Experian Security Freeze

P.O. Box 9554

Allen, TX 75013

TransUnion Fraud Victim Assistance

PO Box 2000

Chester, PA 19016-2000