Form DS-5513 Supplemental Questionnaire to Determine Entitlement for

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE
ENTITLEMENT FOR A U.S. PASSPORT
USE OF SUPPLEMENTAL QUESTIONNAIRE TO ESTABLISH ENTITLEMENT FOR A U.S. PASSPORT
This form is intended to supplement an application for a U.S. passport in the event insufficient evidence of entitlement is provided. In
addition to completing this form, you may be asked to provide further documentary evidence to support your claim. Documentary
evidence should contain your full name, date and/or place of birth, and the seal or other certification of the issuing office (if customary)
and the signature of the issuing official. For more information on proof of U.S. citizenship, please refer to page two of the instructions
for the DS-11, Application for a U.S. Passport, or visit travel.state.gov.

FORM INSTRUCTIONS
1. To assist us in establishing your eligibility for a U.S. passport, please complete this supplemental questionnaire and return it to
the requesting passport office. If you have been asked for additional information and/or documentation, please submit the
information and/or documentation requested with this supplemental questionnaire.
2. Please complete the questions on this form to the best of your knowledge. Generally, the more information you are able to
provide, the faster we may be able to process your U.S. passport application.
3. If you are unsure of the answer to a question, please provide a response to the best of your knowledge. For example, if you
are unsure of an exact address, please provide the city, state, and street name if you can recall them. Passport Services will
consider all the information derived from the form in its entirety.
4. If you have no knowledge of the answer to a question, please write "I don't know." If you believe a particular question
does not apply to you or your circumstances, please write "Not Applicable" or "N/A." The Department realizes that most
information for this questionnaire may be difficult to obtain and will likely come from other sources. The Department will take these
factors into account in the passport issuance process.
5. If you need more space to respond to a question, please write the rest of your response on a separate sheet of paper.

FOR INFORMATION AND/OR QUESTIONS
Please visit our website at travel.state.gov. In addition, contact the National Passport Information Center (NPIC) toll-free at
1-877-487-2778 (TDD 1-888-874-7793) or by e-mail at [email protected]. Customer Service Representatives are available
Monday-Friday, 8:00 a.m.-10:00 p.m. Eastern Time (excluding federal holidays). Automated information is available 24/7.

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.

PRIVACY ACT STATEMENT
AUTHORITIES: Collection of the information solicited on this form is authorized by Titles 8, 22, and 26 of the United States Code, and
other applicable laws and regulations, including 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E, Section 236 of the Admiral
James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001; Executive Order 11295
(August 5, 1966); and 22 C.F.R. parts 50 and 51.
PURPOSE: The primary purpose for soliciting the information is to determine the eligibility of the applicant for a U.S. passport.
ROUTINE USES: The information solicited on this form may be made available as a routine use to other government agencies and
private contractors to assist the U.S. Department of State in adjudicating passport applications and requests for related services, and
for law enforcement, fraud prevention, border security, counterterrorism, litigation activities, and administrative purposes. The
information may be made available to foreign government agencies to fulfill passport control and immigration duties. The information
may also be provided to foreign government agencies, international organizations and, in limited cases, private persons and
organizations to investigate, prosecute, or otherwise address potential violations of law or to further the Secretary's responsibility for
the protection of U.S. citizens and non-citizen nationals abroad. For a more detailed listing of the routine uses to which this
information may be put see the Department of State's Prefatory Statement of Routine Uses relative to the Privacy Act (Public Notice
6290 of July 15, 2008) and the listing of routine users set forth in the System of Records Notices for Overseas Citizen Services
Records (State-05) and Passport Records (State-26) published in the Federal Register.
If you include a social security number, it may be provided to the U.S. Department of Treasury. Failure to provide your social security
number if you have one may subject you to a penalty under federal tax laws. Your social security number may also be used to verify
your identity when adjudicating your passport application and in connection with debt collection, among other purposes as authorized
and generally described in this section.
Providing the information requested on this form, including your social security number, is voluntary. Failure to provide the information
requested may result in processing delays or the denial of your U.S. passport application.

PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 85 minutes per response, including the time required
for searching existing data sources, gathering the necessary data, 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. 20037.
DS-5513 03-2012

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U.S. Department of State

OMB Approval No.: 1405-xxxx
Expiration Date: xx-xx-xxxx
Estimated Burden: 85 minutes

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE
ENTITLEMENT FOR A U.S. PASSPORT
Section A: Biographical Information
1. Full Name:
(First, Middle, Last)

2. Date of Birth:

-

3. Social Security Number:

-

(month)

(day)

(year)

4. Place of Birth (City, State/Country):

Section B: Information about Your Family (Living and Deceased)
Relationship

Full Name

Place of Birth
(City, State, Country)

Date of Birth

Is This Person
a U.S. Citizen?

Example

Example

Example

Example

Example

Sibling

Joe Smith

Anytown, Anystate, USA

12-25-1980

YES

Father/Parent
Stepfather/Parent
Mother/Parent
Stepmother/Parent
Sibling
Sibling
Sibling
Sibling

Section C: Information for Non-Institutional Births or Delayed Birth Filings
Was your birth recorded within one year of the date your birth occurred?

Yes

No

Were you born in a hospital?

Yes

No

If you answered "No" to either of the above questions, please complete items 1 - 5. Otherwise, please continue on to Section D.

1. List all your parent(s) residences one year before your birth:

(Street Address)

(City)

(State and Country)

(Street Address)

(City)

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(State and Country)

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2. Parent(s) place of employment at the time of your birth:
Dates of employment:

Name of employer:

Address of employer:
(Street Address)

(City)

(State and Country)

Name of employer:

Dates of employment:
Address of employer:

(Street Address)

(City)

(State and Country)

3. If your parents were not U.S. citizens at the time of your birth, what type of document, if any, did they use to enter the
United States? Examples include foreign passport, U.S. or a foreign border crossing document, residency card, etc.

4. Mother's medical information:
Did your mother receive medical care while pregnant with you and/or up to one year after your birth?

Yes

Name of hospital or other facility:

Address:
(Street Address)

No
(City)

(State and Country)

Name of Doctor:
Approximate dates of appointments:

Please provide description of birthing location:
(Private home, hospital, clinic, etc.)

Length of time mother stayed at the birthing location listed above?
(One day, three weeks, etc.)

Please provide the names (as well as address and phone number, if available) of persons present at your birth such as
medical personnel, family members, etc:

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Section D: Schools/Day Care Centers/Developmental Programs
Please list any schools, day care centers, or developmental programs you attended from birth to age 18 in or outside of the
United States.
Name of School/Daycare/ Developmental Program

City

State

Country

Dates of Attendance

Example

Example

Example

Example

Example

Washington Elementary

Anytown

Anystate

USA

08-1990 to
06-1994

Section E: Residences
Please list all of your residences inside and outside of the United States starting with your birth until age 18.
Street

City

State

Country

Time of
Residence

Example

Example

Example

Example

Example

123 First St.

Anytown

Anystate

USA

03-1990 to
06-2002

Section F: Signature
I declare under penalty of perjury that all responses contained in this document are true and correct to the best of my
knowledge.

Signature
DS-5513 03-2012

Date
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