AFFIDAVIT REGARDING A CHANGE OF NAME
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
ESTIMATED BURDEN: 15 MINUTES*
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
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)