AUTHORITIES: Collection of this information is authorized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; Executive Order 11295 (August
5, 1996); and 22 C.F.R. parts 50 and 51.
PURPOSE: We are requesting this information in order to determine the place of birth of an applicant for a U.S. passport. The
collection of the Social Security number will be used to verify the identity of you (the affiant) and for no other purpose unless
authorized by law.
ROUTINE USES: This information may be disclosed to another domestic government agency, a private contractor, a foreign
government agency, or to a private person or private employer in accordance with certain approved routine uses. These routine uses
include, but are not limited to, law enforcement activities, employment verification, fraud preven
tion, border security, counterterrorism,
litigation activities, and activities that meet the Secretary of State’s responsibility to protect U.S. citizens and non-citizen nationals
abroad. More information on the routine uses for the system can be found in System of Records Notices State-05, Overseas Citizen
Services Records and Other Overseas Records, and State-26, Passport Records.
DISCLOSURE: Providing your (the affiant’s) Social Security number and other information on this form is voluntary. Given the
form’s purpose of verification of identity and place of birth of an applicant for a U.S. passport, failure to provide the information may
result in processing delays or denial of the passport application.
Public reporting burden for this collection of information is estimated to average 40 minutes per response, including the time required
for searching existing data sources, gathering the necessary data, providing the information and/or documentation required, and
reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control
number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to:
Passport Forms Officer, U.S. Department of State, Bureau of Consular Affairs, Passport Services, Office of Program Management
and Operational Support, 44132 Mercure Cir, PO Box 1199, Sterling, Virginia 20166-1199.
DS-10 10-2020
Page 1 of 2
AFFIANT (The person filling out this form)
False statements made knowingly and willfully in passport applications, including affidavits or other supporting documents submitted
to support this application, are punishable by fine and/or imprisonment under U.S. law, including provisions of 18 U.S.C. 1001, 18
U.S.C. 1542, and/or 18 U.S.C. 1621. Alteration or mutilation of a passport issued pursuant to this application is punishable by fine
and/or imprisonment under the provisions of 18 U.S.C. 1543. The use of a passport in violation of the restrictions contained herein or
of the passport regulations is punishable by fine and/or imprisonment under 18 U.S.C. 1544. All statements and documents are
subject to verification.
This form is used when no birth certificate exists for a person born in the United States or when a U.S. birth certificate was filed more
than a year after birth. This form, or a written statement that includes all of the information on this form, must be filled out by a close
blood relative (for example, an older brother or sister) who has personal knowledge of the details of the passport applicant’s birth or
by a person who was personally involved in the passport applicant’s birth (for example, the attending physician).
• The person filling out this form is the affiant.
• The form is an affidavit. An affidavit is a signed written statement that an affiant swears or affirms is true.
• The form is submitted with an application for a U.S. passport.
The affiant is the person who has personal knowledge of and remembers the passport applicant’s birth (e.g., a close blood relative or
attending physician).
• The affiant must remember and explain the passport applicant’s birth in detail.
• The affiant must submit a clear photocopy of the front and back of the valid identification the affiant presented to the passport agent,
passport acceptance agent, or notary.
The affiant must sign the form or written statement in front of a passport agent, passport acceptance agent, or notary.
• The date of the affiant’s signature must be the same as the date of the passport agent, passport acceptance agent, or notary’s
PASSPORT APPLICANT (The person applying for the passport)
The passport applicant must submit the following:
Delayed birth certificate or Letter of No Record (showing no birth certificate exists)
Early public records (e.g., baptismal certificate, hospital birth certificate early school records)
• Form DS-10, Birth Affidavit completed and signed by the person with personal knowledge of the passport applicant’s birth in front of
a passport agent, passport acceptance agent, or notary
• Form DS-11, Application for a U.S. Passport
Please visit for more information about the requirements for a delayed birth certificate and Letter of No
Record. Birth certificates and Letters of No Record are available from the vital records office in the state you were born. Requests for
copies of this affidavit should be made at the time of execution.
6. How many years have you (the affiant)
known the passport applicant?
8. Write everything you (the affiant) remember about the passport applicant’s birth in detail. Include the date/time/location of
the passport applicant’s birth, individuals present, and any other personal knowledge about the event and how you (the
affiant) obtained knowledg
e of the event. List the names of the passport applicant’s birth parents and your (the affiant’s)
relationship to the passport applicant and/or birth parents. (Attach a separate piece of paper if more space is needed.)
Printed Name of Affiant
(The affiant is the person filling out this form)
Signature of Affiant
Address of Affiant
Identifying Document
Subscribed and Sworn to before me this
Name of Passport Agent, Passport Acceptance Agent, or Notary
DS-10 10-2020
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(Number and Street, City, State, and Zip Code)
Driver's License
(Passport Agency or City & State)
1. Name of Passport Applicant 2. Passport Applicant's Sex
Affiant's Social Security Number
5. Passport Applicant's Current Home Address
3. Passport Applicant's Date of Birth
4. Passport Applicant's Place of Birth (city and state)
7. How do you (the affiant) know the passport applicant? (e.g., Older
brother/sister, mother/father, or physician)
Zip/Postal Code
U.S. Department of State
OMB CONTROL NO. 1405-0132
Affiant's Date of Birth
Sign this form in front of a passport agent, passport acceptance agent, or notary.
• Submit a clear photocopy of the front and back of the valid ID you presented to the passport agent,
passport acceptance agent, or notary.
OATH: I declare under penalty of perjury that the above information given by me is true and correct to the best of my
Military ID
ID Number:
Place of Issue:
Issue Date (mm/dd/yyyy) :
On (mm/dd/yyyy) _________ , the affiant listed above, who is not related to me, personally appeared before me and is known to me to be
the person whose name is subscribed to and acknowledged that he/she executed the same for the uses and purposes therein contained.
I have properly verified the identity of the affiant by personally viewing the above noted identification document and matching photocopy.
Expiration Date
(mm/dd/yyyy) :
Use black ink only. If you make an error, complete a new form. Do not correct.