DS-71
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AUTHORITIES The information solicited on this form may be requested pursuant to provisions in Titles 8 and
22 of the United States Code (U.S.C.), whether or not codified including specifically 22 U.S.C. 211A and all
regulations issued pursuant to Executive Order 11295 (August 5, 1966), including Part 51, Title 22, Code of
Federal Regulations (CFR).
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS
*Public reporting burden for this collection of information is estimated to average 5 minutes per response, including
time required for searching existing data sources, gathering the necessary data, providing the information required,
and reviewing the final collection. You do not have to provide the information unless this collection displays a
currently valid OMB number. Send comments on the accuracy of this estimate of the burden and
recommendations for reducing it to: U.S. Department of State (A/ISS/DIR) Washington, DC 20520.
PURPOSE The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement
to issuance of a U.S. passport. The information may also be used in connection with issuing other travel
documents or evidence of citizenship, and in furtherance of the Secretary's responsibility for the protection of U.S.
nationals abroad.
ROUTINE USES The information solicited on this form may be made available as a routine use to other
government agencies, to assist the U.S. Department of State in adjudicating passport applications and requests for
related services, and for law enforcement and administrative purposes. It may also be disclosed pursuant to court
order. The information may be made available to foreign government agencies to fulfill passport control and
immigration duties or to investigate or prosecute violations of law. The information may also be made available to
private U.S. citizen 'wardens' designated by U.S. embassies and consulates.
Failure to provide the information requested on this form may result in the denial of a United States passport,
related documents, or service to the individual seeking such passport, documents, or service.
False statements made knowingly and willfully in passport applications or in affidavits or other supporting
documents submitted therewith are punishable by fine and/or imprisonment under provisions of 18 U.S.C. 1001
and/or 18 U.S.C. 1542. Alteration or mutilation of a U.S. passport is punishable by fine and/or imprisonment under
provisions of 18 U.S.C. 1543. The use of a U.S. passport in violation of the restrictions contained therein or of the
passport regulations is punishable by fine and/or imprisonment under 18 U.S.C. 1544. All statements and
documents submitted are subject to verification.
WARNING
This affidavit is required to be included with a passport application only when the applicant for a passport is unable to
establish his or her identity to the satisfaction of a person authorized to accept passport applications. The applicant
must still present some identification of his or her own. Witnesses must complete items one through ten (and if
applicable, eleven through thirteen), sign when requested to do so by the same authorized acceptance agent who
accepted the passport application, and present some form of current photo identification of his or her own.
PLEASE PRINT LEGIBLY IN BLUE OR BLACK INK ONLY.
