Fill and Sign the Affidavit Identity Form

Affidavit of Identity and Lack of Social Security Number STATE OF _________________________ COUNTY OF _______________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, _____________________________ , who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. My full legal name is ____________________________________________. 2. My date of birth is _____________________________. 3. My current address is Street Address ____________________________________ City ___________________________ State ___________ Zip Code ______________ 4. I have lived at this address since __________________________ (month/year). 5. My daytime telephone number is (______) ___________________________. 6. My evening telephone number is (______) ___________________________. 7. I have not yet been issued a Social Security Number by the Social Security Administration because (e.g., have applied but application is still being processed) ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. _________________________________________ SWORN to and subscribed before me, this the ______ day of __________________________, 20______. _____________________________ NOTARY PUBLIC My Commission Expires: __________________________