Affidavit Regarding A Change Of Name Page 2
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2For Additional Comments
PRIVACY ACT STATEMENT
AUTHORITIES: We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C.
6039E; Executive Order 11295 (August 5, 1966); and 22 C.F.R. parts 50 and 51.
PURPOSE: We are requesting this information in order to establish the identity ofthe subject of this affidavit as part of
the subject's application for a U.S. passport. The collection of the Social Security number will be used to verify your
identity and for no other purpose unless authorized by law.
ROUTINE USES: This information may be disclosed to another domestic government agency, a private contractor, a
foreign government agency, or to a private person or private employer in accordance with certain approved routine
uses. These routine uses include, but are not limited to, law enforcement activities, employment verification, fraud
prevention, border security, counterterrorism, litigation activities, and activities that meet the Secretary of State's
responsibility to protect U.S. citizens and non-citizen nationals abroad.
More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas
Citizen Services Records and State-26, Passport Records.
DISCLOSURE: Providing your Social Security number and the other information on this form is voluntary, but failure to
provide the information on this form may, given the form's purpose of verification of identity and entitlement to a U.S.
passport, result in processing delays or denial of the passport application.
PAPERWORK REDUCTION ACT STATEMENT
Public 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 Management Officer, U.S.
Department of State, Office of Program Management and Operational Support, 2201 C Street N.W., Washington, DC
20520.
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