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U.S. Department of State
3. Applicant's Date of Birth
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 and must be accompanied by 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 a person who has personal knowledge of the
facts of the birth of the person whose birth in the United States is to be proved. The affidavit shall state briefly how his/her 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.
OMB APPROVAL NO. 1405-0132
EXPIRES: 05-31-2011
ESTIMATED BURDEN: 15 MINUTES*
1. Name of Applicant Whose Birth in the United States is to be proved
Title
Last
MiddleFirst
4. Applicant's Place of Birth
5. Applicant's Current Home Address
City
ZIP Code
State
6. Number of Years
You Have Known the Applicant
8. State all the facts you know about the applicant's birth. State how you obtained this knowledge.
Continue on the back of this form if additional space is required.
I, the undersigned, do solemnly swear that the above information given by me is true and correct to the
best of my knowledge and belief.
Printed Name of Affiant Signature of Affiant
Address of Affiant
Identifying Document Submitted
Subscribed and Sworn to before me this
day of
at
Name of Passport Agent, Acceptance Agent, or Notary Public
Location
DS-10
06-2008
Page 1 of 2
(SEAL)
Male
2. Sex
Female
(Jr.,Sr.,III)
(mm-dd-yyyy)
(Number and Street, City, State, and Zip Code)
(or Affirm)
(Type of Document, Date of Issuance/Expiration, Document Number)
(Affirmed)
(Passport Agency or City & State)
7. Your Relationship to the Applicant OR
The Basis of Your Knowledge Regarding the Applicant
BIRTH AFFIDAVIT
Apartment Number
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 and/or 18 U.S.C. 1542. 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.
Street
Birth Affidavit
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