This affidavit is required 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. Witness must complete items 1 through 6. Please PRINT
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS
AUTHORITIES: The information solicited on this form is requested pursuant to provisions in Titles
8, 18, and 22 of the United States Code, whether or not codified including specifically 22 U.S.C 211A,
212, 213, and all regulations issued pursuant to Executive Order 11295 (August 5, 1966), including Part
51, Title 22, Code of Federal Regulations (CFR). Also, where specifically noted, pursuant to 26 USC
PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and
entitlement to issuance of a US 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 US nationals abroad.
ROUTINE USES: The information solicited on this form is made available as a routine use to other
government agencies, to assist the U.S. Department of State in adjudicating passport applications, 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' designed 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.
*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/RPS/DIR)
Washington, D.C. 20520.
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 multilation of a passport issued pursuant to this application is
punishable by fine and/or imprisonment under provisions of 18 U.S.C. 1543. The use of a 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.
In accordance with 5 CFR 1320 5(b), persons are not required to respond to the collection
of this information unless this form displays a currently valid OMB control number.
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