Get DS-10 2020-2024

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 notary is required with this form. OATH I declare under penalty of perjury that the above information given by me is true and correct to the best of my knowledge. Printed Name of Affiant Signature of Affiant Affiant s Social Security Number Affiant s Date of Birth NOTARY SEAL Address of Affiant Number and Street City State and Zip Code Identifying Document Presented ID Number Driver s License Passport Place of Issue Issue Date mm/dd/yyyy Expiration Date mm/dd/yyyy Affirmed before Subscribed and Sworn Sworn to to Affirmed before me me this this Name of Passport Agent Acceptance Agent or Notary Public DS-10 07-2017 Other specify Military ID day of at Location Passport Agency or City State Page 1 of 2 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. NOTE A clear photocopy of the front and back of the identification you presented to the notary is required with this form. OATH I declare under penalty of perjury that the above information given by me is true and correct to the best of my knowledge. Printed Name of Affiant Signature of Affiant Affiant s Social Security Number Affiant s Date of Birth NOTARY SEAL Address of Affiant Number and Street City State and Zip Code Identifying Document Presented ID Number Driver s License Passport Place of Issue Issue Date mm/dd/yyyy Expiration Date mm/dd/yyyy Affirmed before Subscribed and Sworn Sworn to to Affirmed before me me this this Name of Passport Agent Acceptance Agent or Notary Public DS-10 07-2017 Other specify Military ID day of at Location Passport Agency or City State Page 1 of 2 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 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. U.S. Department of State OMB CONTROL NO. 1405-0132 OMB EXPIRATION DATE 07-31-2020 ESTIMATED BURDEN 40 MINUTES BIRTH AFFIDAVIT Attention Read WARNING INSTRUCTIONS on Page 2 PURPOSE A birth affidavit may 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. The affidavit must be accompanied by a photocopy of the front and back side of the affiant s identification and when applicable 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 an individual who has personal knowledge of the facts of the applicant s birth in the United States it is preferred that the affidavit is made by an older blood relative or by the attending physician. The affidavit must be signed in front of a notary unless it is being submitted to an authorized Passport Agent or Passport Acceptance Agent. The affidavit shall state briefly how the affiant s knowledge was acquired. Requests for copies of this affidavit should be made at the time of execution. 1. Name of Applicant Whose Birth in the United States is to Be Proved Last Suffix Jr. Sr. III First Middle 3.