Office of Vital Registration – Central Valley MaricopaVitalRecords.com
3221 N. 16th St., Ste. 100 • Phoenix, AZ 85016 Mail: P.O. Box 2111 • Phoenix, AZ 85001
Phone: (602) 506-6805 • Fax: (602) 372-8866
North Valley East Valley West Valley
2423 W. Dunlap Ave., Ste. 110 331 E. Coury Ave., 1850 N 95
th
Ave., Ste. 182
Phoenix, AZ 85021 Mesa, AZ 85210 Phoenix, AZ 85037
Identity Verification Form
Request Date: ___________________
Applicant Name: __________________________________ Contact Phone: _______________________
Email Address: __________________________________
Name on Certificate: ____________________________________________________
Important!
All major types of credit cards (Visa, Mastercard, Discover, AMEX) are accepted. Credit card information will not be
collected through this application. A Vital Records Representative will contact you to discuss the status of your
request upon receipt of a completed application.
Once your request is received, a notification receipt will be sent to your email address with a tracking number. You
may call 602-506-6805 option 3 to follow up on the status of your request. Please allow 3-5 business days for
application processing time.
In lieu of uploading your identification to the automated application, complete and sign this form in front of a Notary.
State of ____________________________ County of ___________________________
On this _______ day of ___________, 20 _____ before me personally appeared
__________________________________________ (name of signer), whose identity was
proven to me on the basis of satisfactory evidence to be the person whose name is subscribed
to this document, and who acknowledges that he/she signed the above document.
Notary Signature _________________________________ My Commission Expires _________________________________
Signature and Date Required
Applicant’s Signature: _________________________________________ Date: ________________________
