Last
City
6. Number of years
you have known the applicant
8. State all the facts you know about the applicant's birth. The detailed statement should include the
date/time/location of applicant's birth, individuals present, and any other first-hand knowledge of the event or
how you obtained knowledge of the event. List the names of the applicant's birth parents and your relationship
to the applicant and/or birth parents. (Attach a separate sheet of paper if more space is needed.)
Printed Name of Affiant
Signature of Affiant
Street
Suffix
First
Male
Female
(Jr.,Sr.,III)
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
DS-10 07-2017
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NOTARY
SEAL
(Number and Street, City, State, and Zip Code)
Driver's License
(Passport Agency or City & State)
1. Name of Applicant Whose Birth in the United States is to Be Proved 2. Applicant's Sex
Affiant's Social Security Number
5. Applicant's Current Home Address
3. Applicant's Date of Birth
State
Location
Apartment/Unit
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 may 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 photocopy of the front and back side of the affiant's identification and, when applicable, a notice from the
appropriate authorities indicating that no birth record exists. 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 applicant's birth in the United States; it is preferred that the affidavit is made by an older blood relative
or by the attending physician. The affidavit must be signed in front of a notary, unless it is being submitted to an authorized Passport Agent or Passport Acceptance Agent.
The affidavit shall state briefly how the affiant's knowledge was acquired. Requests for copies of this affidavit should be made at the time of execution.
OMB CONTROL NO. 1405-0132
OMB EXPIRATION DATE: 07-31-2020
ESTIMATED BURDEN: 40 MINUTES
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.
STOP! YOU MUST SIGN THIS FORM IN FRONT OF A PASSPORT AGENT, ACCEPTANCE AGENT, OR NOTARY PUBLIC.
OATH: I declare under penalty of perjury that the above information given by me is true and correct to the best of my
knowledge.
Attention: Read WARNING INSTRUCTIONS on Page 2
Passport Other
Military ID
ID Number:
(specify)
Place of Issue:
Issue Date (mm/dd/yyyy)
Subscribed and Sworn to before me this
Expiration Date
(mm/dd/yyyy)
(Affirmed)
dd mmm yyyy
dd mmm yyyy
click to sign
signature
click to edit
dd mmm yyyy
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
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 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.
DS-10 07-2017
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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.
WARNING
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