Form 1-797 Address Verification / Change Request Identity History S

1-797 (Rev. 10-30-2017)
OMB 1110-

Address Verification/Change Request
Identity History Summary Check
Date
Requestor Name
Last Name

First Name

Middle Name 1

Middle Name 2

Requestor Date of Birth
Previous Address
Address

City

State

Postal (ZIP) Code

Country

I previously sent in a request for my Identity History Summary check. I would like to
verify/change my address.
Please send my request to the following address:
Address

City

State

Postal (ZIP) Code

Country

Email

Phone Number

Sincerely,

(Signature Required)
Please sign, print, and fax this completed form to (304) 625-9792
Or scan and e-mail to [email protected].