AFFIDAVIT REGARDING A CHANGE OF NAME
WARNING False statements made knowingly and willfully on passport applications or on 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.
2. Approximate Date Current Name Was Assumed (mm-yyyy)
3. Former Name of Applicant
4. Applicant's Date of Birth
Suffix
Last
MiddleFirst
6. Number of Years You Have Known the Applicant
7. 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.
(Jr.,Sr.,III)
(mm-dd-yyyy)
(City and State)
(or Name Given on Birth Records)
Suffix Last
First
(Jr.,Sr.,III)
Middle
PURPOSE An Affidavit Regarding a Change of Name may 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 original or certified copies of three or more public documents evidencing that the applicant has used the
acquired name generally for five years or longer. Affidavits Regarding a Change of Name from at least two persons, attesting that they have known the applicant by both
names and that the applicant has used the new name generally 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. The affidavit must be accompanied by a photocopy of the front and back of the affiant's identification. Final determination of the
name(s) to be shown in the U.S. passport will be made by Passport Services based on all submitted evidence. 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: 09-30-2017
ESTIMATED BURDEN: 40 MINUTES
Address of Affiant
Identifying Document Submitted (Type of Document, Date of Issuance and/or Expiration, Document Number)
Subscribed and Sworn to before me this
day of
at
Name of Passport Agent, Acceptance Agent, or Notary Public Location
DS-60 01-2014 Page 1 of 2
(SEAL)
(Number and Street, City, State, and Zip Code )
(Affirmed)
(Passport Agency or City and State)
1. Current Name of Applicant
Printed Name of Affiant Signature of Affiant
Affiant's Social Security Number
5. Applicant's Place of Birth
Please Print Legibly Using Black Ink Only.
