Notarized Proof Of Identification Form Texas

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NOTARIZED PROOF OF IDENTIFICATION
PART I. ENTER NAME, DATE AND PLACE OF BIRTH/DEATH, AND NAMES OF PARENTS AS INFORMATION APPEARS ON
BIRTH/DEATH CERTIFICATE
FULL NAME OF PERSON ON RECORD
DATE OF BIRTH/DEATH
PLACE OF BIRTH/DEATH (City or County)
SEX
FULL NAME OF PARENT 1
FULL NAME OF PARENT 2
PART II. ENTER RELATIONSHIP TO PERSON ON RECORD AND THE TYPE OF ID USED.
NAME AND RELATIONSHIP TO PERSON ON RECORD
TYPE AND NUMBER OF ID ACCEPTED WHEN NOTARIZED
AFFIDAVIT OF PERSONAL KNOWLEDGE
PART III. THIS SECTION MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
STATE OF ______________________
COUNTY OF ____________________
Before me on this day appeared _________________________________________________________________________________
(Name)
Now residing at ______________________________________________________________________________________________,
(Address)
(City)
(State)
Who is related to the person named on Part I as ___________________________________________ and who on oath deposes and
(Relationship)
Says that the contents of this affidavit are true and correct.
Signature ______________________________________________
Sworn to and subscribed before me, this _______ day of ______________________, 20_____.
Signature of Notary Public
(Seal)
Commission Expires
Typed or Printed Name
Street Address
City, State and Zip
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWLINGLY MAKING A FALSE
STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A
FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003)
APPLICATIONS WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED
Mail To:
Vital Statistics
1500 Marilla St. 1FN
Dallas, TX 75201
Document # DWU-FRM-051-VS
Revision # Initial Release
Description of last change: Initial Release
Effective Date: 09/01/2015
Document Title: Notarized Proof of Identification

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