Form DS-71 Affadavit of Identifying Witness

U.S. Department of State

AFFIDAVIT OF IDENTIFYING WITNESS

OMB APPROVAL NO. 1405-0088
EXPIRATION DATE: xx-xx-xxxx
ESTIMATED BURDEN: 5 MINUTES*

(IDENTIFICATION OF A PASSPORT APPLICANT)
This form should be completed ONLY by the identifying witness.
Please print legibly in blue or black ink only.
1. Passport Applicant's Name (Last, First, Middle)

2. Basis of your knowledge concerning the Passport Applicant (Such as your relationship to the applicant)
3. How long have you (The Witness) known the Passport Applicant?
Months

Years

WITNESS INFORMATION
4. Witness' Name (Last, First, Middle)
5. Witness' Residential Address
City, State, ZIP Code

7. Witness Date of Birth (mm-dd-yyyy)

6. Witness' Place of Birth (City, State, Zip Code)

9. Witness Home Telephone Number

8. Witness Daytime Telephone Number

(

)

(

11. Witness Passport Number

)

12. Place of Issue if Known

10. Have you as the Witness been issued a U.S.
Passport?
Yes
No
If yes, continue with questions #11 - 13.
13. Date of Issue (mm-dd-yyyy) If necessary, give
approximate.

NOTE: Read the following oath but DO NOT SIGN the affidavit until requested to do so by an Authorized Acceptance
Agent.
I declare under penalty of perjury that I know or have reason to believe the above-named passport applicant is a citizen
or non-citizen national of the United States; and the above statements are true and correct.
Date (mm-dd-yyyy)

Signature

FOR ACCEPTANCE AGENT'S USE ONLY
Subscribed and sworn to (affirmed) before me

(Seal)

Clerk of Court
Passport Agent

Signature

Location

Postal Employee
(Vice) Consul USA

Date (mm-dd-yyyy)

APPLICANT'S IDENTIFICATION
1. Issued in the Name of

Type of Document

Document Number

Place of Issue

Date of Issue (mm-dd-yyyy)

Date of Expiration (mm-dd-yyyy)

2. Issued in the Name of

Type of Document

Document Number

Place of Issue

Date of Issue (mm-dd-yyyy)

Date of Expiration (mm-dd-yyyy)

Issued in the Name of

Type of Document

Document Number

Place of Issue

Date of Issue (mm-dd-yyyy)

Date of Expiration (mm-dd-yyyy)

WITNESS' IDENTIFICATION

DS-71
xx-xxxx

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USE OF THE AFFIDAVIT OF IDENTIFYING WITNESS: This affidavit is required to be included
with a passport application only when the applicant for a passport is unable to establish his or her
identity to the satisfaction of a person authorized to accept passport applications. The applicant
must still present some identification of his or her own. Witnesses must complete items one
through ten (and if applicable, eleven through thirteen), sign when requested to do so by the same
authorized acceptance agent who accepted the passport application, and present some form of
current photo identification of his or her own.
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 provisions of 18 U.S.C. 1001
and/or 18 U.S.C. 1542. Alteration or mutilation of a U.S. passport is punishable by fine and/or imprisonment under
provisions of 18 U.S.C. 1543. The use of a U.S. 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 submitted are subject to verification.

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS
AUTHORITIES: The information solicited on this form may be requested pursuant to provisions in Titles 8 and
22 of the United States Code (U.S.C.), including specifically 22 U.S.C. 211A, et seq., and all regulations issued
pursuant to Executive Order 11295 (August 5, 1966), including Part 51, Title 22, Code of Federal Regulations
(CFR), and in particular 22 CFR 51.41 and 51.45.
PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement
to issuance of a U.S. passport. The information may also be used in connection with issuing other travel
documents or evidence of citizenship, and in furtherance of the Secretary's responsibility for the protection of U.S.
nationals abroad.

ROUTINE USES: The information solicited on this form may be made available as a routine use to other
government agencies, to assist the U.S. Department of State in adjudicating passport applications and requests for
related services, and for law enforcement and administrative purposes. It may also be disclosed pursuant to court
order. The information may be made available to foreign government agencies to fulfill passport control and
immigration duties or to investigate or prosecute violations of law. The information may also be made available to
private U.S. citizen 'wardens' designated by U.S. embassies and consulates.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Failure to provide the information
requested on this form may result in the denial of a United States passport, related documents, or service to the
individual seeking such passport, documents, or service.
*Public reporting burden for this collection of information is estimated to average 5 minutes per response, including
time required for searching existing data sources, gathering the necessary data, providing the information required,
and reviewing the final collection. You do not have to provide the information unless this collection displays a
currently valid OMB number. Send comments on the accuracy of this estimate of the burden and
recommendations for reducing it to: U.S. Department of State (A/ISS/DIR) Washington, DC 20520.

DS-71

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