(or Name Given on Birth Records)
By Current Name
Suffix
AFFIDAVIT REGARDING A CHANGE OF NAME
3. Applicant's Former Name
4. Applicant's Date of Birth
Middle
6. Number of Years You Have Known the Applicant 7. Your Relationship to the Applicant
By Former Name
8. Explain the difference in the applicant's former name 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. (Attach a separate
sheet of paper if more space is needed.)
OATH: I declare under penalty of perjury 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 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)
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 publicly and exclusively 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 exclusively 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 is not needed if an applicant presents a court order or marriage certificate
documenting the change of his or her name. This affidavit must be signed in front of a notary, unless it is submitted to an authorized Passport Agent or Acceptance Agent.
U.S. Department of State
OMB APPROVAL NO. 1405-0133
EXPIRES: 10-31-2020
ESTIMATED BURDEN: 40 MINUTES
Address of Affiant
Identifying Document
Presented:
Subscribed and Sworn to before me this
day of
at
Name of Passport Agent, Acceptance Agent, or Notary Public Location
DS-60 07-2017
Page 1 of 2
NOTARY
SEAL
(Number and Street, City, State, and Zip Code )
(Affirmed)
(Passport Agency or City & State)
1. Applicant's Current Name
Printed Name of Affiant
Signature of Affiant
Affiant's Social Security Number
5. Applicant's Place of Birth
Attention: Read WARNING on Page 2
2. Approximate Date Current Name Was Assumed (mm-yyyy)
Last
First
STOP! YOU MUST SIGN THIS FORM IN FRONT OF A PASSPORT AGENT, ACCEPTANCE AGENT, OR NOTARY PUBLIC.
Note: A clear photocopy of the front and back of the identification you presented to the passport agent, acceptance agent, or notary is required with this form.
Driver's License Passport
Military ID
Other (specify)
ID Number:
Place of Issue:
Issue Date (mm/dd/yyyy)
Expiration Date (mm/dd/yyyy)
dd mmm yyyy
dd mmm yyyy
click to sign
signature
click to edit
Visit the official Department of State website at travel.state.gov or contact the National Passport Information Center
(NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by e-mail at NPIC@state.gov
. Customer Service
Representatives are available Monday-Friday 8:00a.m.-10:00p.m. and Saturday 10:00a.m.-3:00p.m. Eastern Time
(excluding federal holidays). Automated information is available 24 hours a day, 7 days a week.
FOR INFORMATION AND QUESTIONS
DS-60 07-2017
Page 2 of 2
PRIVACY ACT STATEMENT
PAPERWORK REDUCTION ACT STATEMENT
AUTHORITIES: The information on this form is requested under the authority of 22 U.S.C. 211a et seq.; 8 U.S.C. 1104;
Executive Order 11295 (August 5, 1966); and 22 C.F.R. parts 50 and 51.
PURPOSE: The information collected on this form will be used to establish the identity of the subject of this affidavit as
part of the subject's application for a U.S. passport. The collection of the Social Security number will be used to verify
your identity and for no other purpose unless authorized by law.
ROUTINE USES: This information may be disclosed to another domestic government agency, a private contractor, a
foreign government agency, or to a private person or private employer in accordance with certain approved routine
uses. These routine uses include, but are not limited to, law enforcement activities, employment verification, fraud
prevention, border security, counterterrorism, litigation activities, and activities that meet the Secretary of State's
responsibility to protect U.S. citizens and non-citizen nationals abroad.
More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas
Citizen Services Records and Other Overseas Records, and State-26, Passport Records.
DISCLOSURE: Providing your Social Security number and the other information on this form is voluntary, but failure to
provide the information on this form may, given the form's purpose of verification of identity and entitlement to a U.S.
passport, result in processing delays or denial of the passport application.
Public reporting burden for this collection of information is estimated to average 40 minutes per response, including the
time required for searching existing data sources, gathering the necessary data, providing the information and/or
documentation 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: U.S. Department of State, Bureau of Consular
Affairs, Passport Services, Office of Legal Affairs, Attn: Passport Forms Officer, 44132 Mercure Cir., P.O. Box 1227,
Sterling, VA 20166-1227.
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.
WARNING
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