Performer Record Keeping Compliance Form Pursuant
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1PERFORMER RECORD-KEEPING COMPLIANCE FORM
PURSUANT TO 18 U.S.C. § 2257
PERFORMER IDENTIFYING INFORMATION: Performer understands that all the information
given in this Record-Keeping Compliance Form is being provided to comply with federal law and any
false statement will subject Performer to both civil action by Producer as well as possible criminal
prosecution under federal and state laws.
(a)__________________________________________________________________________________
Legal Family/Last/Surname(s)
___________________________________________________________________________________
Legal Given/First/Middle Name(s)
(b)__________________________________________________________________________________
Date of Birth
(c)
Primary identification document of Performer must be government issued photo ID such as
passport, driver’s license, motor vehicle department ID, or military ID (each should be described,
including the ID number):
Form of Identification:_________________________________________________________________
Issuing Authority:_____________________________________________________________________
ID#:_________________________________________________________________________________
(d) ________________________________________
_______________________________________
Primary Producer
Original Date of This Production
(e)
All other names ever used (including previous legal names, stage names, Web handles, maiden or
married names, aliases, professional names and nicknames):
(1)________________________________________
(a)______________________________________
Stage Name for this Production
All other names
(2)________________________________________
(b)_____________________________________
Maiden Name if Applicable
All other names
(3)________________________________________
(c)______________________________________
Previous Legal name, if applicable
All other names
SWORN STATEMENT: “UNDER 28 U.S.C. § 1746 AND THE PENALTIES OF PURJURY UNDER THE
LAWS OF THE UNITED STATES, I SWEAR THAT ALL INFORMATION I PROVIDED IN THIS
DOCUMENT IS TRUE AND CORRECT AND THAT EACH OF THE IDENTIFICATION DOCUMENTS
WHICH I HAVE PROVIDED ARE TRUE COPIES AND HAVE NOT BEEN FORGED OR ALTERED.”
__________________________________________
_______________________________________
Performer Signature
Date
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