National ID Card Claim Authorization Form

National ID Card Claim Authorization Form
Use this form to submit a claim or authorize collection of a national ID card and provide the details needed to process the request.
Claimant Information
Full Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Cardholder and Claim Details
Cardholder Full Name
First NameMiddle NameLast Name
Relationship to Claimant / Authorized Representative
Claim / Reference Number
Reason for Claim or Authorization
Claim Type
Collection and Supporting Documents
Preferred Collection Branch
Preferred Collection Date and Time
Supporting Documents
Cancelof
Additional Instructions or Notes
Should be Empty: