Ds-10 Form - Us Department Of State
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2OMB CONTROL NO. 1405-0132
U.S. Department of State
OMB EXPIRATION DATE: 07-31-2017
BIRTH AFFIDAVIT
ESTIMATED BURDEN: 40 MINUTES
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. 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.
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. The affidavit must be accompanied by a notice from the appropriate authorities indicating that no birth record exists, and a photocopy of the front
and back side of the affiant's identification. 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 birth of the applicant whose birth in the United States is to be proved. The affidavit shall state briefly how the affiant's
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.
1. Name of Applicant Whose Birth in the United States is to Be Proved
2. 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. State how you obtained this knowledge. List the
names of the applicant's birth parents if you know them.
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
(SEAL)
Address of Affiant
(Number and Street, City, State, and Zip Code)
Identifying Document Submitted
(Type of Document, Date of Issuance/Expiration, Document Number)
NOTE: A clear photocopy of the front and back of the identification you presented to the notary is required with this form.
day of
Subscribed and Sworn to
before me this
(Affirmed)
at
Name of Passport Agent, Acceptance Agent, or Notary Public
Location
(Passport Agency or City & State)
Page 1 of 2
DS-10 06-2014
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