Affidavit of Identity
Full Name: __________________________________________ Date of Birth: ________
Mailing Address: ________________________________ Social Security #: ____________
_________________________________
Home Phone: ___________________ Work Phone: _______________________
Obtain one of the following and complete requested information:
[ ] Driver's License ______________________________
[ ] State ID Card ___________________________
[ ] Passport _________________________________
[ ] Alien Registration Card _______________________________
[ ] Military ID Card ____________________________
[ ] State Issued:________________________
[ ] Country Issued:______________________________________-
Date Issued: (if