Form DS-5520 SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE IDENTITY FOR A U

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE
IDENTITY FOR A U.S. PASSPORT
USE OF SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE IDENTITY FOR A U.S. PASSPORT
This form is intended to supplement an application for a U.S. passport in the event insufficient evidence of identity is provided. In addition to
completing this form, you may be asked to provide further documentary evidence to support your identity claim. Documentary evidence
should contain your full name/photograph (with issue date) or full name/signature (with issue date). For more information on proof of identity,
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 identity for a U.S. passport, please fill out this supplemental questionnaire and return it to the
requesting 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. If you are unable to provide primary evidence of identity such as a previously issued U.S. passport, naturalization certificate, valid
driver's license, valid government-issued identification or another form of primary evidence of identity, please submit secondary
evidence. For lists of primary and secondary evidence of identity, go to http://travel.state.gov/passport and click on the link to
information for first time applicants.
3. 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.
4. 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.
5. Failure to answer every question will not necessarily preclude passport issuance, as the form is considered in its entirety.
6. 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."
7. 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 U.S. passport 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; 22 U.S.C 2714a(f),
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 your entitlement to be issued a U.S. passport. The collection of
the Social Security number will be used for identity/entitlement to passport verification 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 information on this form is voluntary, but failure to provide your Social Security number on your passport
application may result in the denial of your application (consistent with 22 U.S.C 2714a(f))

PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 45 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. Responding to this collection of information is voluntary. 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 Legal Affairs and Law
Enforcement Liaison, 44132 Mercure Circle, P.O. Box 1227, Sterling, VA, 20166-1227.
DS-5520 XX-XXXX

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U.S. Department of State

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE
IDENTITY FOR A U.S. PASSPORT
Section A: Biographical Information

OMB Approval No.: 1405-0215
Expiration Date: XX-XX-XXXX
Estimated Burden: 45 minutes

1. Full Name:

(First, Middle, Last)

2. Date of Birth:
(month)

-

(day)

3. Social Security Number:

(year)

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

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

Full Name

Place of Birth (U.S. City
& State or City & Country)

Anytown,
Anystate, USA

Joe Smith

Current Address

Date of Birth

12-25-1980

123 Elm St. Anytown,
Anystate

Father/Parent
Stepfather/Parent
Mother/Parent
Stepmother/Parent
Brother/Sister
Brother/Sister
Brother/Sister
Brother/Sister
Spouse

Section C: Employment
Please list your last four places of employment (if applicable)

If self-employed or a contractor working remotely, provide your home addresses.
If active duty military, provide 4 most recent duty stations.
Company Name & Address

Job Title

U.S. City & State or
City & Country

Country

Time Employed

ABC Industries/1001 West Elm Drive

Writer

Anytown, Anystate

USA

2004-2008

DS-5520 XX-XXXX

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Section D: Schools
Please list all schools that you attended inside and outside of the United States (or as many as possible)
Name of School

City

State

Country

Washington Elementary

Anytown

Anystate

USA

Dates of Attendance

08-1990 to 06-1994

Section E: Residences
Please list your five most recent permanent residences (or as many as possible)
Temporary residences of less than 90 days may be omitted
Street

123 First St.

City

Anytown

State

Anystate

Zip Code

Country

11011

USA

Time of
Residence

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-5520 XX-XXXX

Date
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