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Accounts offered by American Express National Bank.

Affidavit of Identity

STATE OF
COUNTY OF

The undersigned affiant, on this day personally appeared before me, and having presented a valid picture I.D. in the form
of a

, who after being duly sworn, on penalty of perjury, deposes
Driver’s License, State Identification, Passport, Military Identification

and says:
My name is

, and I am the person identified in the picture I.D.

presented to the undersigned authority. I make this affidavit in connection with a bank account held in the name of with
American Express National Bank.

Full Name of Affiant:
Address of Affiant:
City

State

Zip Code

Social Security Number of Affiant:
Signature of Affiant:

Subscribed and sworn to before me, this

day of
(day of the month)

(Seal)

, 20
(month)

.
(year)

Signature of Notary:

Full Name of Notary:
My commission expires:

PLEASE SUBMIT REQUEST VIA FAX OR MAIL TO ONE OF THE FOLLOWING
Fax: 1-800-542-0779
Mail: American Express National Bank,