Form A - Proof Of Citizenship Demonstration And Declaration

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FORM A 
Name: ___________________________________________________ Account #_______________________________   
Business Name:  
Business Location and Tax ID No.:  
 
 
For Official Use Only
F
A
ORM
 
Citizenship status confirmed by _____________________________ Date _________________
 
Proof of Citizenship Demonstration and Declaration
In order for an individual, including an individual who is a sole proprietor or a partner in a partnership, who is a U.S. Citizen to
conduct a public records transaction with the City of Mobile, Alabama, each such individual/citizen must declare his or her U.S.
citizenship by executing the declaration at the bottom of this form, and must demonstrate his or her U.S. citizenship by presenting a
legible copy of one of the following items.
Note: If the presented item does not show the person’s current legal name, please also provide a copy of supporting document to
verify the legal name change.
Please check which of the listed items has been provided.
A driver's license or non-driver's identification card issued by the Alabama Department of Public Safety or the equivalent
governmental agency of another state within the United States, provided that the governmental agency of another state within
the United States requires proof of lawful presence in the United States as a condition of issuance of the driver's license or
non-driver's identification card.
A birth certificate indicating birth in the United States or one of its territories.
Pertinent pages of a United States valid or expired passport identifying the person and the person's passport number or the
person's United States passport.
United States naturalization documents or the number of the certificate of naturalization.
Other documents or methods of proof of United States citizenship issued by the federal government pursuant to the
Immigration and Nationality Act of 1952, as amended.
Bureau of Indian Affairs card number, tribal treaty card number, or tribal enrollment number.
A consular report of birth abroad of a citizen of the United States of America.
A certificate of citizenship issued by the United States Citizenship and Immigration Services.
A certification of report of birth issued by the United States Department of State.
An American Indian card, with KIC classification, issued by the United States Department of Homeland Security.
Final adoption decree showing the person's name and United States birthplace.
An official United States military record of service showing the applicant's place of birth in the United States.
An extract from a United States hospital record of birth created at the time of the person's birth indicating the place of birth in
the United States.
AL-verify.
A valid Uniformed Services Privileges and Identification Card.
Any other form of identification that the Alabama Department of Revenue authorizes, through an administrative rule
promulgated pursuant to the Alabama Administrative Procedure Act, to be used to demonstrate or confirm a person's United
States citizenship or lawful presence in the United States, provided that the identification requires proof of lawful presence in
the United States as a condition of issuance.
CITIZENSHIP DECLARATION
 
Under penalty of perjury, I, ________________________________________________,
(print name of undersigned)
the undersigned do hereby declare that I am a citizen of the United States of America.
Date ________________________
_________________________________________________
Declarant’s Signature

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