Fillable Printable Affidavit of Birth Form Sample

Affidavit of Birth Form Sample

AUTHORITIES: The information solicited on this form is requested pursuant to provisions in Titles 8, 18, and 22 of the United States Code, whether or not codified,

including specifically 22 U.S.C. 211a, 212, and 213, and all regulations issued pursuant to Executive Order 11295 (August 5, 1966), including Part 51, Title 22, Code of

Federal Regulations (CFR). Also, as noted, 26 U.S.C. 6039E.

PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to issuance of a U.S. passport. The information may also be

used in connection with issuing other travel documents or evidence of citizenship, and in furtherance of the Secretary's responsibility for the protection of U.S. nationals abroad.

ROUTINE USES: The information solicited on this form may be made available as a routine use to other government agencies to assist the U.S. Department of State in

adjudicating passport applications, and for law enforcement and administrative purposes. It may also be disclosed pursuant to court order. The information may be made

available to foreign government agencies to fulfill passport control and immigration duties or to investigate or prosecute violations of law. The information may also be made

available to private U.S. citizen 'wardens' designated by U.S. embassies and consulates.

Failure to provide the information requested on this form may also result in the denial of a United States passport, related document, or service to the individual seeking such

passport, document, or service.

*Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time required for searching existing data

sources, gathering the necessary data, providing the information required, and reviewing the final collection. You do not have to provide the information unless this

collection displays a currently valid OMB number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S.

Department of State (A/RPS/DIR) Washington, DC 20520.

Completed affidavits will be retained by Passport Services. Copies desired should be made at the time of execution.

U.S. Department of State

BIRTH AFFIDAVIT

OMB Approval No. 1405-00132

Expires : 11/30/2004

Estimated burden 15 Minutes*

When an acceptable birth certificate cannot be obtained for a person born in the United States, a birth affidavit, accompanied by a notice from appropriate authorities indicating

no birth record exists, may be submitted with an application for a passport. The birth affidavit form may also be submitted in conjunction with other birth records.

The birth affidavit should be made by a person who has knowledge of the date and place of birth of the person whose birth in the United States is to be proved. The affidavit

shall state briefly how and through what source the 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.

Subscribed and sworn to (affirmed) before me this

(Address of affiant: number and street, city, state and ZIP code)

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.

(Passport Agent, Postal Employee, Clerk of Court or Notary Public)

day of

(Identifying document submitted: type of document, date of issuance or expiration, serial number)

(Impression seal)

NAME OF PERSON WHOSE BIRTH IN THE UNITED STATES IS TO BE PROVED SEX

GIVE COMPLETE FACTS ON WHICH THE PLACE AND DATE OF BIRTH ARE BASED. IF AFFIANT IS NOT CLOSELY RELATED TO PERSON WHOSE BIRTH IN

THE UNITED STATES IS TO BE PROVED, STATE HOW AND THROUGH WHAT SOURCE THE PERSONAL KNOWLEDGE WAS ACQUIRED (Continue on reverse,

if necessary)

NUMBER OF YEARS YOU HAVE KNOWN THIS PERSON

PERSON'S PLACE OF BIRTH (City and State)

PERSON'S DATE OF BIRTH (mm-dd-yyyy)

PERSON'S PRESENT RESIDENCE (Street address, City, State and ZIP code) IF DECEASED, SO STATE

RELATIONSHIP TO OR BASIS OF YOUR

KNOWLEDGE REGARDING THIS PERSON

Male

Female

WARNING:

False statements made knowingly and willfully in passport applications or in affidavits or other supporting documents submitted therewith, including this

form, may be punishable by fine and/or imprisonment under the provisions of 18 U.S.C. 1001 and/or 18 U.S.C. 1542.

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS

(Signature of affiant)

(Printed or typed name of affiant)

DS-10

12-2001