U. S. Department of State
DS-5507
01-2016
AFFIDAVIT OF PHYSICAL PRESENCE OR RESIDENCE, PARENTAGE AND SUPPORT
OMB NO. 1405-0187
EXPIRES - 02-29-2020
Estimated Burden - 30 minutes
Page 1 of 5
I, do solemnly swear (or affirm):
That I am a U.S. citizen/U.S. non-citizen national by:
1) birth in on
2) naturalization on
before the
City/Town, State in the United States Date
Date Name of Court and State
3) birth abroad on
Date (mm-dd-yyyy)
to U.S. citizen(s) or U.S. non-citizen national(s) in
(mm-dd-yyyy)
(mm-dd-yyyy)
(Continued on the next page)
CONSULAR AND PASSPORT OFFICES OF THE UNITED STATES OF AMERICA
PART I
That I am
(mm-dd-yyyy)
to
Name of Child
Date of Birth
Place of Birth
(Continue on a separate sheet, if necessary)
Name
Name
(All applicants please complete Part I)
(choose one)
Country
Married
(choose all that apply)
married on
Date
That I am the biological parent of:
Country
in
Previously Married
(mm-dd-yyyy)
Single
If terminated, list date and manner of termination (e.g. death or divorce)
(Please use a separate sheet to list additional marriages and marriage termination information.)
or enter N/A.
DS-5507
Page 2 of 5
(Continued on the next page)
That I have been physically present or have had a residence in the United States as follows:
Place
(Continue on a separate sheet, if necessary)
(City, State)
Date
(mm-dd-yyyy)
Date
(mm-dd-yyyy)
From To
Place
Purpose:
That I have been physically present or resident abroad as follows:
(Country)
(Continue on a separate sheet, if necessary)
(Indicate purpose of stay: vacation, residence,
business, studies, U.S. government employment,
U.S. government/military service or dependent, etc.
If working abroad give name of employer)
From To
(mm-dd-yyyy)
Date Date
(mm-dd-yyyy)
That the other biological parent of the above-named child/children for whom this application for a Consular Report of Birth and/or U.S.
passport is being filed is:
is a citizen or national of the U.S.
is not a citizen of the U.S.
If the other parent is a U.S. citizen/U.S. non-citizen national it is by:
1) birth in
on
2) naturalization on before the
City/Town, State in the United States
Date
Date
Name of Court and State
3) birth abroad on
Date
to U.S. citizen(s)/U.S. non-citizen national(s) in
(mm-dd-yyyy)
(mm-dd-yyyy)
(mm-dd-yyyy)
Country
From
To
From To
From To
From To
From To
From To
From To
Name
Purpose
(Indicate purpose of stay: vacation, residence,
business, studies, etc.)
From To
From To
From To
From To
From To
From To
Place
(City, State)
Date
(mm-dd-yyyy)
Date
(mm-dd-yyyy)
The other biological parent has been physically present or has had a residence in the United States as follows: (INFORMATION ABOUT
THE UNMARRIED NON-APPLYING PARENT SHOULD ONLY BE PROVIDED IF THAT PARENT IS A U.S. CITIZEN OR U.S.
NON-CITIZEN NATIONAL)
(Continue on a separate sheet, if necessary)
Part II of this document must be signed before a Consular Officer, Passport Specialist, or designated
Consular/Acceptance Agent at the time the oath is sworn.
Subscribed and sworn before me this day of
, .
[SEAL]
Signature and Title of Consular Officer, Passport
Specialist or designated Consular/Acceptance
Agent Administering Oath
My child was born out of wedlock, and I am the biological father through whom such child is claiming U.S. citizenship. I agree to
provide financial support for such child until he/she reaches the age of eighteen years.
Signature of Affiant
PLEASE STOP HERE!
(All applicants with a child/children born out of wedlock)
PART II
DS-5507
Page 3 of 5
(Continued on the next page)
Purpose
(Indicate purpose of stay: vacation, residence,
business, studies, etc.)
Part III of the document must be signed before a Consular Officer, Passport Specialist, or designated
Consular/Acceptance Agent at the time the oath is sworn.
SUBSCRIBED AND SWORN TO (AFFIRMED) before me this day of
,
at
,
Signature and Title of Administering Officer
,
[SEAL]
DS-5507
Page 4 of 5
WARNING: False statements made knowingly and willfully in applications for citizenship documentation or affidavits and other supporting
documents are punishable by fine and/or imprisonment under the provisions of 18 USC 1001 and other applicable criminal statutes.
A U.S. Consular Officer or Passport Specialist may require additional evidence of one's blood relationship to one's child and/or evidence of
one's physical presence or residence in the United States.
I solemnly swear (or affirm) that all the statements contained in this affidavit are true and complete to the best of my knowledge and belief,
and that this affidavit is for the purpose of establishing my relationship to the aforementioned child/children and his/her/their claim to U.S.
citizenship.
Signature of affiant
PART III
(Oath: To be completed by all applicants)
Present Street Address
State
Country
City
Zip Code Telephone Number
PLEASE STOP HERE.
PRIVACY ACT STATEMENT
AUTHORITY: The State Department is authorized to collect this information pursuant to
8 U.S.C. § 1104(a)(1), 1104(a)(3), 1401, 1408, 1409, 22 U.S.C. § 211(a) and 213.
PURPOSE: The principal purpose of the information gathered is to determine if a U.S.
citizen/national parent(s) has met the statutory physical presence or residence
requirements to transmit U.S. citizenship to his/her child born abroad or in the United
States for U.S. non-citizen nationality; to establish parentage of the child; and to fulfill
the requirements of 8 U.S.C. 1409(a), which permits acknowledgment of paternity under
oath and requires the U.S. citizen father’s written agreement to provide financial support
for his children born abroad out of wedlock.
ROUTINE USES: The information solicited on this form may be made available to
Federal government entities such as the Social Security Administration, the Department
of Homeland Security, and Department of Justice, in connection with determinations of
citizenship status, administration of federal benefits, and law enforcement purposes as
set forth in the System of Records Notice for Overseas Citizens Records, STATE-05, 73
FR 24342 (2008) and the Department wide Prefatory Statement of Routine Uses, 73 FR
40649-40651 (2008). Information also can be made available to appropriate federal, state,
local or foreign government entities, such as state law enforcement agencies, state
prosecutors, judicial staff, local police, and INTERPOL, in connection with law
enforcement, safety, welfare and related matters, as set forth by the System of Records
Notice for Overseas Citizens Records, STATE-05, 73 FR 24342 (2008). These matters
include custody disputes and notification of next of kin.
Furnishing the information on this form is voluntary; however, failure to furnish the
requested information may delay or prevent you from documenting your child as a U.S.
citizen or national.
PAPERWORK REDUCTION ACT (PRA) STATEMENT
Public reporting burden for this collection of information is estimated to average 30
minutes per response, including time required for searching existing data sources,
gathering the necessary documentation, providing the information and/or documents
required, and reviewing the final collection. You do not have to supply this information
unless this collection displays a currently valid OMB control number. If you have
comments on the accuracy of this burden estimate and/or recommendations for
reducing it, please send them to: CA/OCS/PMO, 10th Floor, SA-17, U.S. Department of
State, Washington, DC 20036.
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DS-5507
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