AFFIDAVIT REGARDING A CHANGE OF NAME
WARNING False statements made knowingly and willfully on passport applications or on 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.
2. Approximate Date Current Name Was Assumed (mm-yyyy)
3. Former Name of Applicant
4. Applicant's Date of Birth
6. Number of Years You Have Known the Applicant
7. Your Relationship to the Applicant
By Current Name
By Former Name
Explain the variance in the applicant's name shown on his/her birth records and the name currently used. State
whether the current name is used exclusively and for all purposes or if it is used as an "also known as" name.
Continue on the back of this form if additional space is required.
I solemnly swear (or affirm) that the information given above by me is true and correct to the best of my knowledge and belief; that the
applicant named abo ve has been kno wn by both h is or her p resent an d forme r names as stated and is o ne and the s ame person; that
the applicant is known by his or her present name to friends and relatives, and in the community in which he or she is residing.
(City and State)
(or Name Given on Birth Records)
PURPOSEAn Affidavit Regarding a Change of Name may be submitted with an application for a U.S. passport when the name which is used by the applicant is (1)
substantially different from that shown on the evidence of citizenship or (2) has been adopted without formal court proceedings and was not acquired by a marriage. The
affiant (preferably a blood relative) must have personal knowledge of the applicant's use of both names. To support a change of name that has been adopted without formal
court proceedings or by a marriage, the applicant must present original or certified copies of three or more public documents evidencing that the applicant has used the
acquired name generally for five years or longer. Affidavits Regarding a Change of Name from at least two persons, attesting that they have known the applicant by both
names and that the applicant has used the new name generally for at least five years, may be provided in place of one of the public documents if the applicant cannot
obtain a third public document. The affidavit must be accompanied by a photocopy of the front and back of the affiant's identification. Final determination of the
name(s) to be shown in the U.S. passport will be made by Passport Services based on all submitted evidence. Completed affidavits will be retained and requests for copies
of this affidavit should be made at the time of execution. An affidavit does not need to be submitted if an applicant can present a court order documenting the change of
U.S. Department of State
OMB APPROVAL NO. 1405-0133
ESTIMATED BURDEN: 40 MINUTES
Address of Aff iant
Identifying Document Submitted (Type of Document, Date of Issuan ce and/or Expi ration, Document Number)
Subscribed and Sworn to before me this
Name of Passport Agent, Acceptance Agent, or Notary Public Location
DS-60 01-2014 Page 1 of 2
(Number and Street, City, State, and Zip Code )
(Passport Agency or City and State)
1. Current Name of Applicant
Printed Name of AffiantSignatur e o f Affiant
Affiant's Social Security Number
5. Applican t ' s Place of Birth
Please Print Legibly Using Black Ink Only.
For Additional Comments
Page 2 of 2
PRIVACY ACT STATEMENT
PAPERWORK REDUCTION ACT STATEMENT
AUTHORITIES: We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C.
6039E; Executive Order 11 29 5 (August 5, 1966); an d 22 C.F.R. part s 50 a nd 51.
PURPOSE: We are requesting this information inorder to establish the identity ofthe subject of this affidavit as part of
the subject's application for a U.S. passport. The collection of the Social Security number will be used to verify your
identity and for 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 in formation on this f orm is volunta ry, but failure t o
provide the information on this form may, given the form's purpose of verification of identity and entitlement to a U.S.
passport, result in processing delays or denial of the passport application.
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: Passport Forms Management Officer, U.S.
Department of State, Office of Program Management and Operational Support, 2201 C Street N.W., Washington, DC