Form D-10 Birth Affidavit

U.S. Department of State
OMB CONTROL NO. 1405-0132
OMB EXPIRATION DATE: XX-XX-XXXX
ESTIMATED BURDEN: 40 MINUTES

BIRTH AFFIDAVIT
Attention: Read WARNING INSTRUCTIONS on Page 2

PURPOSE A birth affidavit may be submitted (with an application for a U.S. passport) when an acceptable birth certificate cannot be obtained for a person born in the United
States. When applicable, the affidavit must be accompanied by a notice from the appropriate authorities indicating that no birth record exists, and a photocopy
of the front and back side of the affiant's identification. A birth affidavit may also be submitted in conjunction with other birth records. A birth affidavit must be made by
an individual who has personal knowledge of the facts of the applicant's birth in the United States; it is preferred that the affidavit is made by an older blood relative or by the
attending physician. The affidavit must be signed in front of a notary, unless it is being submitted to an authorized Passport Agent or Passport Acceptance Agent. The
affidavit shall state briefly how the affiant's knowledge was acquired. Requests for copies of this affidavit should be made at the time of execution.

1. Name of Applicant Whose Birth in the United States is to Be Proved
Last

Suffix (Jr.,Sr.,III)

First

Middle

3. Applicant's Date of Birth

2. Applicant's Sex
Male
Female

4. Applicant's Place of Birth (City and State)

5. Applicant's Current Home Address
Street

Apartment/Unit
State

City
6. Number of years
you have known the applicant

Zip Code

7. Your relationship to the applicant OR
the basis of your knowledge regarding the applicant

8. State all the facts you know about the applicant's birth. The detailed statement should include the
date/time/locaton of applicant's birth, individuals present, and any other first-hand knowledge of the event or
how you obtained knowledge of the event. List the names of the applicant's birth parents and your relationship
to the applicant and/or birth parents. (Attach a seperate sheet of paper if more space is needed.)

STOP! YOU MUST SIGN THIS FORM IN FRONT OF A PASSPORT AGENT, ACCEPTANCE AGENT, OR NOTARY PUBLIC.
NOTE: A clear photocopy of the front and back of the identification you presented to the notary is required with this form.

OATH: I declare under penalty of perjury that the above information given by me is true and correct to the best of my
knowledge.

Printed Name of Affiant

Signature of Affiant

Affiant's Social Security Number

Affiant's Date of Birth
NOTARY
SEAL

Address of Affiant (Number and Street, City, State, and Zip Code)
Identifying Document
Presented:
ID Number:

Driver's License

Passport
Place of Issue:

Issue Date (mm/dd/yyyy)

Expiration Date (mm/dd/yyyy)

(Affirmed) before
Subscribed
Subscribed and
and Sworn
Sworn to
to(Affirmed)
before me
me this
this

Name of Passport Agent, Acceptance Agent, or Notary Public
DS-10 XX-XXXX

Other (specify)

Military ID

day of
at

Location (Passport Agency or City & State)
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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: The information on this form is requested under the authority of 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: The purpose for requesting this information is to determine the place of birth of an applicant for 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 the place of birth of an applicant for 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: U.S. Department of State, Bureau of Consular Affairs, Passport Services, Office of Legal Affairs and Law Enforcement Liaison,
Attn: Passport Forms Officer, 44132 Mercure Cir., P.O. Box 1227, Sterling, Virginia 20166-1227.

DS-10 XX-XXXX

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