Birth Affidavit Form. This is a Official Federal Forms form and can be use in Passport US Department Of State.
Tags: Birth Affidavit, DS-10, Official Federal Forms US Department Of State, Passport
U.S. Department of State OMB APPROVAL NO. 1405-0132 EXPIRES: 07-31-2014 ESTIMATED BURDEN: 15 MINUTES BIRTH AFFIDAVIT 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 A birth affidavit should 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 notice from the appropriate authorities indicating that no birth record exists and a photocopy of the front and back side of the affiant's identification. A birth affidavit may also be submitted in conjunction with other birth records. A birth affidavit must be made by a person who has personal knowledge of the facts of the birth of the person whose birth in the United States is to be proved. The affidavit shall state briefly how his/her knowledge was acquired. It is preferred that the affidavit be made by an older blood relative, although it may be made by the attending physician or any other person who has personal knowledge of the birth. Completed affidavits will be retained by Passport Services. Requests for copies of this affidavit should be made at the time of execution. 1. Name of Applicant Whose Birth in the United States is to be proved Last Suffix First 2. Sex Middle (Jr.,Sr.,III) Male Female 3. Applicant's Date of Birth (mm-dd-yyyy) 4. Applicant's Place of Birth (City and State) 5. Applicant's Current Home Address Street Apartment/Unit City ZIP Code State 6. Number of years you have known the applicant 7. Your relationship to the applicant OR the basis of your knowledge regarding the applicant 8. State all the facts you know about the applicant's birth. State how you obtained this knowledge. Continue on the back of this form if additional space is required. I, the undersigned, do solemnly swear (or Affirm) that the above information given by me is true and correct to the best of my knowledge and belief. Printed Name of Affiant Signature of Affiant Affiant's Social Security Number Address of Affiant (SEAL) (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-10 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-10 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com