USA Patriot Act Information Form

Autotagged version will look like this. 

4 Required Radio Dials + 4 Un-Required Text Boxes for the following:

• State Issued Driver License - If Radio 1 is selected, complete 4 un-required Text Boxes

• State Issued ID Card - If Radio 2 is selected,  complete 4 un-required Text Boxes

• Passport - If Radio 3 is selected, complete 4 un-required Text Boxes

• US Alien Registration Card or Green Card- If Radio 4 is selected, complete 4 un-required Text Boxes (See image below for help)

“Comments:” 1 Un-Required Text Box

Notary Signature tag

Notary Date Signed tag

Notary Full Name tag

Un-Required Text Tag for Printed Title and add “Notary” or “Notary Public” or "NSA"