Statement Of Information Confidential Information For Your Protection
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1
2STATEMENT OF INFORMATION
CONFIDENTIAL INFORMATION FOR YOUR PROTECTION
Completion of this statement expedites your application for title insurance, as it assists in establishing identity, eliminating matters affecting persons
with similar names and avoiding the use of fraudulent or forged documents. Complete all blanks (please print) or indicate "none" or "N/A." If more
space is needed for any item(s), use the reverse side of the form. Each party (and spouse/domestic partner, if applicable) to the transaction should
personally sign this form.
NAME AND PERSONAL INFORMATION
Date of Birth
First Name
Middle Name
Last Name
Maiden Name
(If none, indicate)
Home Phone
Business Phone
Birthplace
Social Security No.
Driver’s License No.
List any other name you have used or been known by
State of residence
I have lived continuously in the U.S.A. since
Are you currently married?
If yes, complete the following information:
Date and place of marriage
Spouse:
Date of Birth
First Name
Middle Name
Last Name
Maiden Name
(If none, indicate)
Home Phone
Business Phone
Birthplace
Social Security No.
Driver’s License No.
List any other names you have used or been known by
State of residence
I have lived continuously in the U.S.A. since
Are you currently a registered domestic partner?
If yes, complete the following information:
Domestic Partner:
Date of Birth
First Name
Middle Name
Last Name
Maiden Name
(If none, indicate)
Home Phone
Business Phone
Birthplace
Social Security No.
Driver’s License No.
List any other names you have used or been known by
State of residence
I have lived continuously in the U.S.A. since
*************************************************************************************************************************
CHILDREN
Child Name:
Date of Birth:
Child Name:
Date of Birth:
Child Name:
Date of Birth:
Child Name:
Date of Birth:
(If more space is required, use reverse side of form)
*************************************************************************************************************************
RESIDENCES (LAST 10 YEARS)
Number & Street
City
From (date) to (date)
Number & Street
City
From (date) to (date)
(If more space is required, use reverse side of form)
*************************************************************************************************************************
OCCUPATIONS/BUSINESSES (LAST 10 YEARS)
Firm or Business name
Address
From (date) to (date)
Firm or Business name
Address
From (date) to (date)
(If more space is required, use reverse side of form)
Page 1 of 2
UE-34 (Rev. 06-08)
Statement of Information (statinfo)(06-08)
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