Form DS-71 Affidavit 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 and is to ONLY be
used in conjunction with form DS-11, Application for a U.S. Passport.
This affidavit must be accompanied by a photocopy of the front and back side of the witness' identification.
1. Passport Applicant's Name (Last, First, Middle)

2. How do you know the applicant?
3. How long have you (the Witness) known the passport applicant?
Years

Months

WITNESS INFORMATION
4. Witness' Name (Last, First, Middle)

5. Witness' Residential Address

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

8. Witness' Home Telephone Number

(

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

9. Witness' Social Security Number

)

11. Witness' Passport Number

12. Place of Issue (if known)

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

NOTE TO THE WITNESS: 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
Acceptance Agent
(Seal)
Passport Staff Agent

Signature

(Vice) Consul USA

Location

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

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USE OF 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, 11 through 13), 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. The affidavit must be
accompanied by a photocopy of the front and back side of the witness' identification.

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
U.S. 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
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 are subject to verification.

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 determine entitlement to a U.S. passport. The collection of the Social Security number will
be used to verify your identity only and 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 5 minutes per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents 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: U.S. Department of State, Bureau of Consular
Affairs, Passport Services, Office of Program Management and Operational Support, 2201 C Street NW, Washington, D.C. 20520.

DS-71 07-2013

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