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