Proof of Residency Form
Applicant Name
*
First Name
Last Name
*
By marking this box, I affirm that I have lived in the State of Ohio CONTINUOUSLY for the last five (5) years. Listed below is my current address and a list of my prior residences for the last five (5) years.
By marking this box, I affirm that I have NOT lived in the State of Ohio CONTINUOUSLY for the last five (5) years.
I attest that the information that I have documented is correct. I further understand that I am required to show proof of residency(List of acceptable documentation is available).
*
Clear
Date
*
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Month
-
Day
Year
Date
Current Residence
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates of residency (From):
to
*
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates of residency (From):
to
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates of residency (From):
to
Submit
Should be Empty: