Fillable Printable Form DS-5507

Form DS-5507

U. S. Department of State

DS-5507

01-2016

AFFIDAVIT OF PHYSICAL PRESENCE OR RESIDENCE, PARENTAGE AND SUPPORT

OMB NO. 1405-0187

EXPIRES - 11-30-2018

Estimated Burden - 30 minutes

Page 1 of 5

I, do solemnly swear (or affirm):

That I am a U.S. citizen/U.S. non-citizen national by:

1) birth inon

2) naturalization on

before the

City/Town, State in the United StatesDate

Date Name of Court and State

3) birth abroad on

Date (mm-dd-yyyy)

to U.S. citizen(s) or U.S. non-citizen national(s) in

(mm-dd-yyyy)

(Continued on the next page)

CONSULAR AND PASSPORT OFFICES OF THE UNITED STATES OF AMERICA

PART I

That I am

(mm-dd-yyyy)

Name of Child

Date of Birth

Place of Birth

(Continue on a separate sheet, if necessary)

Name

(All applicants please complete Part I)

(choose one)

Country

Married

(choose all that apply)

married on

Date

That I am the biological parent of:

Country

Previously Married

(mm-dd-yyyy)

Single

If terminated, list date and manner of termination (e.g. death or divorce)

(Please use a separate sheet to list additional marriages and marriage termination information.)

or enter N/A.

DS-5507

Page 2 of 5

(Continued on the next page)

That I have been physically present or have had a residence in the United States as follows:

Place

(Continue on a separate sheet, if necessary)

(City, State)

Date

(mm-dd-yyyy)

Date

(mm-dd-yyyy)

FromTo

Place

Purpose:

That I have been physically present or resident abroad as follows:

(Country)

(Continue on a separate sheet, if necessary)

(Indicate purpose of stay: vacation, residence,

business, studies, U.S. government employment,

U.S. government/military service or dependent, etc.

If working abroad give name of employer)

FromTo

(mm-dd-yyyy)

Date Date

(mm-dd-yyyy)

That the other biological parent of the above-named child/children for whom this application for a Consular Report of Birth and/or U.S.

passport is being filed is:

is a citizen or national of the U.S.

is not a citizen of the U.S.

If the other parent is a U.S. citizen/U.S. non-citizen national it is by:

1) birth in

2) naturalization onbefore the

City/Town, State in the United States

Date

Name of Court and State

3) birth abroad on

Date

to U.S. citizen(s)/U.S. non-citizen national(s) in

(mm-dd-yyyy)

Country

From

FromTo

Name

Purpose

(Indicate purpose of stay: vacation, residence,

business, studies, etc.)

FromTo

Place

(City, State)

Date

(mm-dd-yyyy)

Date

(mm-dd-yyyy)

The other biological parent has been physically present or has had a residence in the United States as follows: (INFORMATION ABOUT

THE UNMARRIED NON-APPLYING PARENT SHOULD ONLY BE PROVIDED IF THAT PARENT IS A U.S. CITIZEN OR U.S.

NON-CITIZEN NATIONAL)

(Continue on a separate sheet, if necessary)

Part II of this document must be signed before a Consular Officer, Passport Specialist, or designated

Consular/Acceptance Agent at the time the oath is sworn.

Subscribed and sworn before me thisday of

, .

[SEAL]

Signature and Title of Consular Officer, Passport

Specialist or designated Consular/Acceptance

Agent Administering Oath

My child was born out of wedlock, and I am the biological father through whom such child is claiming U.S. citizenship. I agree to

provide financial support for such child until he/she reaches the age of eighteen years.

Signature of Affiant

PLEASE STOP HERE!

(All applicants with a child/children born out of wedlock)

PART II

DS-5507

Page 3 of 5

(Continued on the next page)

Purpose

(Indicate purpose of stay: vacation, residence,

business, studies, etc.)

Part III of the document must be signed before a Consular Officer, Passport Specialist, or designated

Consular/Acceptance Agent at the time the oath is sworn.

SUBSCRIBED AND SWORN TO (AFFIRMED) before me this day of

Signature and Title of Administering Officer

[SEAL]

DS-5507

Page 4 of 5

WARNING: False statements made knowingly and willfully in applications for citizenship documentation or affidavits and other supporting

documents are punishable by fine and/or imprisonment under the provisions of 18 USC 1001 and other applicable criminal statutes.

A U.S. Consular Officer or Passport Specialist may require additional evidence of one's blood relationship to one's child and/or evidence of

one's physical presence or residence in the United States.

I solemnly swear (or affirm) that all the statements contained in this affidavit are true and complete to the best of my knowledge and belief,

and that this affidavit is for the purpose of establishing my relationship to the aforementioned child/children and his/her/their claim to U.S.

citizenship.

Signature of affiant

PART III

(Oath: To be completed by all applicants)

Present Street Address

State

Country

City

Zip CodeTelephone Number

PLEASE STOP HERE.

PRIVACY ACT STATEMENT

AUTHORITY: The State Department is authorized to collect this information pursuant to

8 U.S.C. § 1104(a)(1), 1104(a)(3), 1401, 1408, 1409, 22 U.S.C. § 211(a) and 213.

PURPOSE: The principal purpose of the information gathered is to determine if a U.S.

citizen/national parent(s) has met the statutory physical presence or residence

requirements to transmit U.S. citizenship to his/her child born abroad or in the United

States for U.S. non-citizen nationality; to establish parentage of the child; and to fulfill

the requirements of 8 U.S.C. 1409(a), which permits acknowledgment of paternity under

oath and requires the U.S. citizen father’s written agreement to provide financial support

for his children born abroad out of wedlock.

ROUTINE USES: The information solicited on this form may be made available to

Federal government entities such as the Social Security Administration, the Department

of Homeland Security, and Department of Justice, in connection with determinations of

citizenship status, administration of federal benefits, and law enforcement purposes as

set forth in the System of Records Notice for Overseas Citizens Records, STATE-05, 73

FR 24342 (2008) and the Department wide Prefatory Statement of Routine Uses, 73 FR

40649-40651 (2008). Information also can be made available to appropriate federal, state,

local or foreign government entities, such as state law enforcement agencies, state

prosecutors, judicial staff, local police, and INTERPOL, in connection with law

enforcement, safety, welfare and related matters, as set forth by the System of Records

Notice for Overseas Citizens Records, STATE-05, 73 FR 24342 (2008). These matters

include custody disputes and notification of next of kin.

Furnishing the information on this form is voluntary; however, failure to furnish the

requested information may delay or prevent you from documenting your child as a U.S.

citizen or national.

PAPERWORK REDUCTION ACT (PRA) STATEMENT

Public reporting burden for this collection of information is estimated to average 30

minutes per response, including time required for searching existing data sources,

gathering the necessary documentation, providing the information and/or documents

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: CA/OCS/PMO, 10th Floor, SA-17, U.S. Department of

State, Washington, DC 20036.

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DS-5507