DS-0010 Application Form Download PDF >> Birth Affidavit
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AUTHORITIES : Collection of this information is authorized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; Executive O rder 11295 (August 5, 1996) ; and 22 C.F.R. parts 50 and 51. PURPOSE : We are requesting t his information in order t o determine the place of birth of an applicant for a U.S. passport. The collection of the S ocial S ecurity number will be used t o v erify the identity of you (the affiant) and f or no other purpose unless authorized by law. ROUTINE USES : This information may be disclosed t o another domestic government agency, a private c ontractor, a f oreign governmen t agen cy, or t o a private person or private employer in accordance with c ertain approved routine uses . These routine uses include , but are not limited t o, law enforcemen t activities, employment verification, fraud preven tion, border security, counterterrorism, litigation activities, and activities that meet the S ecretary of State’s responsibility to protect U.S. citizens and non-citizen nationals abroad . More information on t he routine uses for t he system c an be f ound in S ystem of Records Notices State-05, Overseas Citizen Services Records and Other Overseas Records, and State-26, Passport Records. DISCLOSURE : Providing your (t he a ffiant ’s) Social Security number and other information on this form is voluntary. Given t he form’s purpose of verification of identity and place of birth of an applicant for a U.S. passport, failure t o provide t he information may result in processing dela ys or denial of the passport application. PRIVACY ACT STATEMENT PAPERWORK REDUCTION ACT STATEMENT Pub lic 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 Officer, U.S. Department of State, Bureau of Consular Affairs, Passport Services, Office of Program Management and Operational Support, 44132 Mercure Cir, PO Box 1199, Sterling, Virginia 20166-1199. DS- 10 10 -20 20 Page 1 of 2 AFFIANT (The person filling out this form) False statements made knowingly and wi llfully in passport applications, including affidavits or other supporting documents submitted to support this application, are punishable by fine and/or imprisonment under U.S. law, including 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 herein 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. WARNING USE OF THIS FORM This form is used when no birth certificate exists for a person born in the United States or when a U.S. birth certificate was filed more than a year after birth. This form, or a written statement that includes all of the information on this form, must be filled out by a close blood relative (for example, an older brother or sister) who has personal knowledge of the details of the passport applicant’s birth or by a person who was personally involved in the passport applicant’s birth (for example, the attending physician). • The person filling out t his form is the affiant. • The form is an affidavit. An affidavit is a signed written statement that an affiant swears or affirms is true. • The form is submitted with an application for a U.S. passport. The affiant is the person who has personal knowledge of and remembers the passport applicant’s birth (e.g., a close blood relative or attending physician). • The affiant must remember and explain the passport applicant’s birth in detail. • The affiant must submit a clear photocopy of t he front and back of the valid identification the affiant presented to the passp ort agent, passport acceptance agent, or notary. • The affiant must sign the form or written statement in front of a passport agent, passport acceptance agent, or notary. • The date of t he affiant’s signature must be the same as the date of the passport agent, passport acceptance agent, or notary’s signature. PASSPORT APPLICANT (The person applying for the passport) The passport applicant must submit t he following: • Delayed birth certificate or Letter of No Record (showing no birth certificate exists) • Early public records (e.g., baptismal certificate, hospital birth certificate early school records) • Form DS-10, Birth Aff idavit completed and signed by the person with personal knowledge of the passport applicant’s birth in front of a passport agent, passport acceptance agent, or notary • Form DS-11, Application for a U.S. P assport Please visit t ravel.state.gov/citizenship for more information about t he requirements for a delayed birth certificate and Letter of No Record. Birth certificates and Letters of No Record are available from the vital records office in the state you were born. Req uests for copies of t his affidavit should be made at t he time of execution. Last City 6. How many years have you (the affiant) known the passport a pplicant? 8. Wri te everything you (the affian t) rememb er a bout the passport a
pplicant’s birth in detail. Inc lude the date/ti me/location of the passport a pplicant’s birth, indiv iduals present , and any oth er p ersona l knowle dge a bout the event a nd how y ou (the affiant ) obtained kn owl ed g e of the event. List the na mes of the pa ssport ap plicant’s birth parent s an d yo ur (the affiant’s) rela tionsh ip to the pa ssport ap plicant an d/or birth parent s. ( Attach a s epa rate piece of pape r if mor e spa ce i s ne eded .) Printed Name of Affiant (The affiant is the person filling out this form) Signature of Affiant Street Suffix First Male Female ( Jr.,Sr.,III ) Address of Affiant Identifying Document Presented: Subscribed and Sworn to before me this at Name of Passport Agent, Passport Acceptance Agent, or Notary DS- 10 10 -2 0 20 Page 2 of 2 NOTARY SEAL ( Number and Street, City, State, and Zip Code ) Driver's License (Passport Agency or City & St ate) 1. Name of Passport Applicant 2. Passport Applicant's Sex Affiant's Social Security Number 5. Passport Applicant's Current Home Address 3. Passport Applicant's Date of Birth State/Country Location Apartment/Unit 4. Passport Applicant's Place of Birth ( city and state ) (Affi rmed) 7. How do you (the affiant) know the p assport applicant? (e.g., Older brother/sister, mother/father, or physician) Zip/Postal Code BIRTH AFFIDAVIT U.S. Department of State OMB CONTROL NO. 1405-0132 EXPIRATION DATE: 10-31-2023 ESTIMATED BURDEN: 40 MINUTES Middle Affiant's Date of Birth Y OU (TH E AFFIANT) MUST: • Sign t his fo rm in front of a passport agent , passport accep tan ce agent , or notary. • Submit a clear photocopy of the front and back of the valid ID you presented to the passport agent, passport acceptance agent, or notary. OATH: I declare under penalty of perjury that the above inform ation given by me is true and corr ect to the b est of my kno wledge. rehtO tropssaP Military ID ID N umber: ( specify ) Place of Issue: Issue Date ( mm/dd/yyyy ) : On ( mm/dd/yyyy ) _________ , the affiant listed above, who is not related to me, personally appeared before me and is known to me to be the person whose name is subscribed to and acknowledged that he/she executed the same for the uses and purposes therein contained. I have properly verified the identity of the affiant by personally viewing the above noted identification document and matching photocopy. Expiration Date ( mm/dd/yyyy ) : Use black ink only. If you make an error, complete a new form. Do not correct.
|Application Name||DS-0010 Application Form Download PDF|
|Form Title||Birth Affidavit Application Form Download PDF|
|Form Process||Online / Offline|