Notarized Identity Verification
PRINT NAME:________________________________________________________________
(First Name, Middle Initial, Last Name)
E-mail Address (optional): ______________________________________________________
Address:____________________________________________________________________
City:________________________________ State:__________ Zip Code: _______________
I hereby represent that all above information is true and accurate.
Signature: ___________________________________________
(Sign in the Presence of a Notary)
State of _________________________
County of _______________________
I hereby certify that on this ______day of ________________________, 20___________
Personally appeared before me the signer and subject of the above form, who signed or attested to the same in
my presence, and presented the following form of identification as proof of his or her identity:
Driver’s License or Govt. Identification Card
U.S. Passport
U.S. Military ID Card
State Identification Card
Social Security Card
Birth Certificate
Other: _______________________________________________________________
(provide description)
Notary Public: ____________________________________________
(Print Name)
My Commission Expires: ____________________________________
Notary Public Signature: ____________________________________
Reserved for Notary Seal