U.S. Department of State AFFIDAVIT REGARDING A CHANGE OF NAME OMB APPROVAL NO. 1405-0133 EXPIRES: 07/31/2014 *ESTIMATED BURDEN: 15 MINUTES WARNING 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. PURPOSE An Affidavit Regarding a Change of Name must 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 three or more public documents showing exclusive use of the name for at least five years. 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 for all purposes 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 side 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 of the evidence submitted. 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. 1. Current Name of Applicant Last First Suffix (Jr.,Sr.,III) Middle 2. Approximate Date Current Name Was Assumed 4. Former Name of Applicant (mm-yyyy) 3. Number of Years You Have Known the Applicant (or Name Given on Birth Records) Last Title First Middle 5. Applicant's Date of Birth (mm-dd-yyyy) 6. Applicant's Place of Birth 7. Number of Years You Have Known the Applicant By Current Name (Jr.,Sr.,III) (City and State) 8. Your Relationship to the Applicant 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. Printed Name of Affiant Signature of Affiant Affiant's Social Security Number (SEAL) Address of Affiant (Number and Street, City, State, and ZIP Code ) Identifying Document Submitted (Type of Document, Date of Issuance/Expiration, Document Number) Subscribed and Sworn to (Affirmed) before me this day of at Name of Passport Agent, Acceptance Agent, or Notary Public DS-60 07-2011 Location (Passport Agency or City and State) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 For Additional Comments PRIVACY ACT STATEMENT AUTHORITIES Collection of the information solicited on this form is authorized by Titles 8, 22, and 26 of the United States Code, and other applicable laws and regulations, including 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; Section 236 of the Admiral James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001; Executive Order 11295 (August 5, 1966); and 22 C.F.R. parts 50 and 51. PURPOSE The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to the issuance of a U.S. passport. ROUTINE USES The information solicited on this form may be made available as a routine use to other government agencies and private contractors to assist the U.S. Department of State in adjudicating passport applications and requests for related services, and for law enforcement, fraud prevention, border security, counterterrorism, litigation activities, and administrative purposes. The information may be made available to foreign government agencies to fulfill passport control and immigration duties. The information may also be provided to foreign government agencies, international organizations and, in limited cases, private persons and organizations to investigate, prosecute, or otherwise address potential violations of law or to further the Secretary's responsibility for the protection of U.S. citizens and non-citizen nationals abroad. The information may be made available to the Department of Homeland Security and private employers for employment verification purposes. For a more detailed listing of the routine uses to which this information may be put see the Department of State's Prefatory Statement of Routine Uses relative to the Privacy Act (Public Notice 6290 of July 15, 2008) and the listing of routine users set forth in the System of Records Notices for Overseas Citizen Services Records (State-05) and Passport Records (State-26) published in the Federal Register. Your social security number is being requested to assist in establishing and verifying your identity, a critical element that bears on your credibility as an affiant. Providing your social security number will also assist in expediting the adjudication of the passport application of the applicant. If you do not have a social security number, you may write 000-00-0000. PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is estimated to average 15 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: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20520-2202. DS-60 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2