WARNING 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 the provisions of 18 U.S.C. 1001 and/or 18 U.S.C. 1542. 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 therein 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.
6. Applicant's Place of Birth
3. Number of Years You Have Known the Applicant
PURPOSE An Affidavit Regarding a Change of Name must be submitted with an application for a U.S. passport when the name which is used by
the applicant is (1) substantially different from that shown on the evidence of citizenship or (2) has been adopted without formal court proceedings and
was not acquired by a marriage. The affiant (preferably a blood relative) must have personal knowledge of the applicant's use of both names. To
support a change of name that has been adopted without formal court proceedings or by a marriage, the applicant must present three or more public
documents showing exclusive use of the name for at least five years. Affidavits Regarding a Change of Name from at least two persons attesting that
they have known the applicant by born names and that the applicant has used the new name for all purposes for at least five years may be provided in
place of one of the public documents if the applicant cannot obtain a third public document. Final determination of the name(s) to be shown in the U.S.
passport will be made by Passport Services based on all of the evidence submitted. Completed affidavits will be retained and requests for copies of
this affidavit should be made at the time of execution. An Affidavit does not need to be submitted if an applicant can present a court order
documenting the change of their name.
U.S. Department of State
OMB APPROVAL NO. 1405-0133
EXPIRES: 05/31/2011
1. Current Name of Applicant
2. Approximate Date Current Name Was Assumed
4. Former Name of Applicant
5. Applicant's Date of Birth
7. Number of Years You Have Known the Applicant
8. Your Relationship to the Applicant
By Current Name By Former Name
Explain the variance in the applicant's name shown on his/her birth records and the name currently used. State
whether the current name is used exclusively and for all purposes or if it is used as an "also known as" name.
Continue on the back of this form if additional space is required.
I solemnly swear (or affirm) that the information given above by me is true and correct to the best of my knowledge and belief, that the
applicant named above has been known by both his or her present and former names as stated and is one and the same person; that
the applicant is known by his or her present name to friends and relatives, and in the community in which he or she is residing.
Printed Name of Affiant
Signature of Affiant
Address of Affiant
Identifying Document Submitted (Type of Document, Date of Issuance/Expiration, Document Number)
Subscribed and Sworn to before me this
day of
Name of Passport Agent, Acceptance Agent, or Notary Public
Page 1 of 2
(City and State)
(Number and Street, City, State, and Zip Code )
(Passport Agency or City and State)
(or Name Given on Birth Records)
AUTHORITIES: The information solicited on this form is 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, 212, 213, and all
regulations issued pursuant to Executive Order 11295 (August .5, 1966), including Part 51, Title 22, Code of Federal
Regulations (CFR).
PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to
the 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 of State'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 (such as the FBI, DHS, etc.), 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 for use in emergency
evacuation situations.
Failure to provide the information requested on this form may result in the denial of a United States passport, related
document, or service to the individual seeking such passport, document, or service.
Page 2 of 2
For Additional Comments
*Public reporting burden for this collection of information is estimated to average 15 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 are not required to respond to the collection of information unless this form
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.