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Get DS-60 2020-2021

U.S. Department of State AFFIDAVIT REGARDING A CHANGE OF NAME Attention Read WARNING on Page 2 OMB APPROVAL NO. Completed affidavits will be retained and requests for copies of this affidavit should be made at the time of execution. An affidavit is not needed if an applicant presents a court order or marriage certificate documenting the change of his or her name. 1405-0133 EXPIRES 10-31-2020 ESTIMATED BURDEN 40 MINUTES PURPOSE An 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. 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 exclusively 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. Attach a separate sheet of paper if more space is needed. STOP YOU MUST SIGN THIS FORM IN FRONT OF A PASSPORT AGENT ACCEPTANCE AGENT OR NOTARY PUBLIC. Note A clear photocopy of the front and back of the identification you presented to the passport agent acceptance agent or notary is required with this form. OATH I declare under penalty of perjury that the information given above by me is true and correct to the best of my knowledge and belief that the applicant named above has been known by both his or her present and former names as stated and 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. Signature of Affiant Printed Name of Affiant Affiant s Social Security Number Address of Affiant NOTARY SEAL Number and Street City State and Zip Code Identifying Document Presented ID Number Driver s License Passport Military ID Other specify Place of Issue Issue Date mm/dd/yyyy Expiration Date mm/dd/yyyy Subscribed and Sworn to Affirmed before me this day of at Name of Passport Agent Acceptance Agent or Notary Public DS-60 07-2017 Location Passport Agency or City State Page 1 of 2 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. Note A clear photocopy of the front and back of the identification you presented to the passport agent acceptance agent or notary is required with this form. OATH I declare under penalty of perjury that the information given above by me is true and correct to the best of my knowledge and belief that the applicant named above has been known by both his or her present and former names as stated and 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. Signature of Affiant Printed Name of Affiant Affiant s Social Security Number Address of Affiant NOTARY SEAL Number and Street City State and Zip Code Identifying Document Presented ID Number Driver s License Passport Military ID Other specify Place of Issue Issue Date mm/dd/yyyy Expiration Date mm/dd/yyyy Subscribed and Sworn to Affirmed before me this day of at Name of Passport Agent Acceptance Agent or Notary Public DS-60 07-2017 Location Passport Agency or City State Page 1 of 2 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. Signature of Affiant Printed Name of Affiant Affiant s Social Security Number Address of Affiant NOTARY SEAL Number and Street City State and Zip Code Identifying Document Presented ID Number Driver s License Passport Military ID Other specify Place of Issue Issue Date mm/dd/yyyy Expiration Date mm/dd/yyyy Subscribed and Sworn to Affirmed before me this day of at Name of Passport Agent Acceptance Agent or Notary Public DS-60 07-2017 Location Passport Agency or City State Page 1 of 2 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..

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