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On-Line File 10 Entry Form

  1. COLLECT File 10- Identity Theft Entry Form

  2. By completing and signing this form, I am giving my consent to be entered as a File 10*

  3. You need to be a victim of an Identity Theft. Please provide your case number. If you do not have your case number, complete the Online ID Theft complaint form and when assigned a case number re-apply for the FIle 10. If you were assigned a case number, but forgot it, please call 203-622-8024 for assistance in retreiving your case number.

  4. mm-dd-yyyy-

  5. Important- DO NOT FORGET PASSWORD. A password can be anything you wish.

  6. MM-DD-YYYY

  7. Yes or No

  8. Feet -Inches

  9. Lbs

  10. XXX-XX-XXXX

  11. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  12. Leave This Blank:

  13. This field is not part of the form submission.