U.S. Department of State BIRTH AFFIDAVIT OMB CONTROL NO. 1405-0132 OMB EXPIRATION DATE: 07-31-2017 ESTIMATED BURDEN: 40 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 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 an individual who has personal knowledge of the facts of the birth of the applicant whose birth in the United States is to be proved. The affidavit shall state briefly how the affiant's 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 Suffix (Jr.,Sr.,III) Last First 3. Applicant's Date of Birth Middle 4. Applicant's Place of Birth (City and State) 2. Sex Male Female 5. Applicant's Current Home Address Street City 6. Number of years you have known the applicant State Apartment/Unit Zip Code 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. List the names of the applicant's birth parents if you know them. I declare under penalty of perjury that the above information given by me is true and correct to the best of my knowledge. Printed Name of Affiant Signature of Affiant Affiant's Social Security Number Affiant's Date of Birth Address of Affiant (Number and Street, City, State, and Zip Code) Identifying Document Submitted (Type of Document, Date of Issuance/Expiration, Document Number) (SEAL) NOTE: A clear photocopy of the front and back of the identification you presented to the notary is required with this form. Subscribed and Sworn to (Affirmed) before me this Name of Passport Agent, Acceptance Agent, or Notary Public DS-10 06-2014 day of at Location (Passport Agency or City & State) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 PRIVACY 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; 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. 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 Program Management and Operational Support, 2201 C Street, NW, Washington, D.C. 20520. DS-10 06-2014 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com