AUTHORITIES: The information on this form is requested under the authority of 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C.
6039E; Executive Order 11295 (August 5, 1966); and 22 C.F.R. parts 50 and 51.
PURPOSE: The purpose for requesting this information is to determine the place of birth of an applicant for a U.S. passport. The
collection of the Social Security number will be used to verify your identity only and 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
More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas Citizen Services
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 the place of birth of an applicant for a U.S.
passport, result in processing delays or denial of the passport application.
PRIVACY ACT STATEMENT
PAPERWORK REDUCTION ACT STATEMENT
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 and Law Enforcement Liaison,
Attn: Passport Forms Officer, 44132 Mercure Cir., P.O. Box 1227, Sterling, Virginia 20166-1227.
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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.