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pdf1-797 (Rev. 1-31-2024)
OMB 1110-0072
Address Verification/Change Request
Identity History Summary Check
Order Number
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 e-mail signed form to [email protected].
| File Type | application/pdf |
| File Modified | 2024-01-25 |
| File Created | 2023-12-14 |