6. Number of years
you have known the applicant
8. State a ll the facts you kn o w about th e 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 separat e she et o f p aper if more space is ne ed ed . )
Printed Name of Affiant
Signature of Affiant
Address of Af f i a nt
Identifying Docu ment
Subscribed and Sworn to before me this
Name of Passport Agent, Acceptance Agent, or Notary Public
Page 1 of 2
(Number and Street, City, State, and Zip Code)
(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 Soc ial Security Number
5. Applicant's Current Home Address
3. Applicant's Date of Birth
4. Applicant's Place of Birth (City and State)
7. Your relationship to the applicant OR
the basis of your knowledge regarding the applicant
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 CONTRO L NO. 1405-0132
OMB EXPIRATION D A TE: 07-3 1-2020
ESTIMATED BURDEN: 40 MINUTES
Affiant's Date of Bi rth
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 abo ve information given by me is true an d correct to the best of my
Attention: Read WARNING INSTRUCTIONS on Page 2
Place of Issue:
Issue Date (mm/dd/yyyy)
Subscribed and Sworn to before me this
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 authorize d by law.
ROUTINE USES: This information may be disclosed to another domestic government agency, a private contractor, a foreign
government agency, or to a p rivate perso n o r private employer in accordance with certain appro ved routine u ses. T hese ro utine uses
include, but are not limi ted to, law enforceme nt activities, employment verificati on, fraud preventi on, border securi ty, counterterrorism,
litigation activities, and activities that meet the Secretary of State's responsibility to protect U.S. citizens and non-citizen nationals
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 STATEME NT
Public reporting burden for this collecti on of information is estimate d to average 40 minutes per response, including th e time required
for searching existing data sources, gathering the necessary data, providing the information and/or documentation required, and
reviewing the final co llection. You do not h ave to supply this info rmation 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 122 7, Sterling , Virginia 20166-1227.
Page 2 of 2
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 regu lations is
punishable by fine and/or imprisonment under 18 U.S.C. 1544. All statements and documents are subject to verification.