Form Ds-10 - Birth Affidavit - Us Department Of State
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1
2U.S. Department of State
OMB CONTROL NO. 1405-0132
BIRTH AFFIDAVIT
OMB EXPIRATION DATE: 07-31-2020
Attention: Read WARNING INSTRUCTIONS on Page 2
ESTIMATED BURDEN: 40 MINUTES
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
2. Applicant's Sex
Suffix
Last
(Jr.,Sr.,III)
Male
First
Middle
Female
3. Applicant's Date of Birth
4. Applicant's Place of Birth (City and State)
5. Applicant's Current Home Address
Street
Apartment/Unit
State
Zip Code
City
6. Number of years
7. Your relationship to the applicant OR
you have known the applicant
the basis of your knowledge regarding the applicant
8. State all the facts you know about the applicant's birth. The detailed statement should include the
date/time/location of applicant's birth, individuals present, and any other first-hand knowledge of the event or
how you obtained knowledge of the event. List the names of the applicant's birth parents and your relationship
to the applicant and/or birth parents. (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 Date of Birth
Affiant's Social Security Number
NOTARY
Address of Affiant
(Number and Street, City, State, and Zip Code)
SEAL
Identifying Document
Presented:
Driver's License
Passport
Other
(specify)
Military ID
ID Number:
Place of Issue:
Issue Date (mm/dd/yyyy)
Expiration Date (mm/dd/yyyy)
day of
Subscribed and Sworn to
before me this
Subscribed and Sworn to
before me this
(Affirmed)
(Affirmed)
at
Name of Passport Agent, Acceptance Agent, or Notary Public
Location
(Passport Agency or City & State)
Page 1 of 2
DS-10 07-2017
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