Last
City
6. Number of years
you have known the applicant
8. State all the facts you know about the applicant's birth. State how you obtained this knowledge. List the
names of the applicant's birth parents if you know them.
Printed Name of Affiant
Signature of Affiant
Street
Suffix
First
Male
Female
(Jr.,Sr.,III)
Address of Affiant
Identifying Document Submitted
Subscribed and Sworn to before me this
day of
at
Name of Passport Agent, Acceptance Agent, or Notary Public
DS-10 06-2014
Page 1 of 2
(SEAL)
(Number and Street, City, State, and Zip Code)
(Type of Document, Date of Issuance/Expiration, Document Number)
(Passport Agency or City & State)
1. Name of Applicant Whose Birth in the United States is to Be Proved 2. Sex
Affiant's Social Security Number
5. Applicant's Current Home Address
3. Applicant's Date of Birth
State
Location
Apartment/Unit
I declare under penalty of perjury that the above information given by me is true and correct to the best of my
knowledge.
4. Applicant's Place of Birth (City and State)
(Affirmed)
7. Your relationship to the applicant OR
the basis of your knowledge regarding the applicant
Zip Code
BIRTH AFFIDAVIT
U.S. Department of State
PURPOSE A birth affidavit should be submitted (with an application for a U.S. passport) when an acceptable birth certificate cannot be obtained for a person born in the
United States. The affidavit must be accompanied by a notice from the appropriate authorities indicating that no birth record exists, and a photocopy of the front
and back side of the affiant's identification. A birth affidavit may also be submitted in conjunction with other birth records. A birth affidavit must be made by an individual
who has personal knowledge of the facts of the birth of the applicant whose birth in the United States is to be proved. The affidavit shall state briefly how the affiant's
knowledge was acquired. It is preferred that the affidavit be made by an older blood relative, although it may be made by the attending physician, or any other person who
has personal knowledge of the birth. Completed affidavits will be retained by Passport Services. Requests for copies of this affidavit should be made at the time of
execution.
OMB CONTROL NO. 1405-0132
OMB EXPIRATION DATE: 07-31-2017
ESTIMATED BURDEN: 40 MINUTES
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, 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 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.
Middle
Affiant's Date of Birth
NOTE: A clear photocopy of the front and back of the identification you presented to the notary is required with this form.
