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

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE
IDENTITY FOR A U.S. PASSPORT
USE OF THIS FORM
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 Instruction page 1 of the DS-11, Application for a U.S. Passport, or visit travel.state.gov/identification.

IMPORTANT
1. All questions must be answered to the best of your knowledge. The more information you are able to provide, the faster we may be
able to process your U.S. passport application. For example, if you are unsure of an exact address, please provide the city, state, and
street name if you can recall them. The Department of State will consider all the information derived from the form in its entirety.
2. Please submit the information and/or documentation requested with this supplemental questionnaire to the requesting passport office.
3. 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 travel.state.gov/identification.
4. If you don’t know 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 responses on a separate sheet of paper.
.

FOR INFORMATION AND/OR QUESTIONS
For passport and travel information, please visit travel.state.gov. In addition, contact the National Passport Information Center (NPIC) toll-free
at 1-877-487-2778 (TDD/TTY 1-888-874-7793) or by email at [email protected].
.

WARNING

False statements made knowingly and willfully in passport applications, including affidavits or other documents submitted to support this
application, are punishable by fine and/or imprisonment under U.S. law including 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 herein 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. Failure to provide
information requested on this form, including your Social Security number, may result in significant processing delays and/or the
denial of your application.

PRIVACY ACT STATEMENT
AUTHORITIES: Collection of this information is authorized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 22 U.S.C. 2714a(f); 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 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 Other Overseas
Records and State-26, Passport Records.
DISCLOSURE: Providing information on this form is voluntary. Be advised, however, that failure to provide the information requested on this
form may cause delays in processing your U.S. passport application and/or could result in the refusal or denial of your application. Failure to
provide your Social Security number may result in the denial of your application (consistent with 22 U.S.C. 2714a(f)) and may subject you to
a penalty enforced by the Internal Revenue Service, as described in the Warning section of the instructions to this form. Your Social Security
number will be provided to the Department of the Treasury and may be used in connection with debt collection, among other purposes
authorized and generally described in this section.

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. 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, 44132 Mercure Circle, PO Box
1199, Sterling, VA, 20166-1199.
DS-5520 xx-xxxx

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U.S. Department of State

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE
IDENTITY FOR A U.S. PASSPORT

OMB Approval No.: 1405-0215
Expiration Date: xx-xx-xxxx
Estimated Burden: 45 minutes

Section A: Biographical Information
1. Full Name:

(First, Middle, Last)

2. Date of Birth:

-

(month)

3. Social Security Number:

-

(day)

(year)

4. Place of Birth:

(U.S. City & State or City & Country)

Section B: Family (Living and Deceased)

(Fill in as much information as possible. Attach a separate sheet, if needed.)
Relationship

Full Name

(Include maiden name, if applicable)

Joe Smith

Brother

Place of Birth

Date of Birth

Current Address

Anytown, Anystate

12-25-1980

123 Elm St Anytown, Anystate USA

(U.S. City & State or City & Country)

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

Section C: Employment

(Fill in as much information as possible. Attach a separate sheet, if needed.)

Please list your places of employment (if applicable) starting with your last three.
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

DS-5520 xx-xxxx

Job Title

U.S. City & State or
City & Country

Country

Time Employed

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Section D: Schools

(Fill in as much information as possible. Attach a separate sheet, if needed.)
Please list all schools that you attended inside and outside of the United States.
Name of School

City

State

Anytown

Country

Dates of Attendance

Anystate

Section E: Residences

(Fill in as much information as possible. Attach a separate sheet, if needed.)
Please list all your permanent residences starting with the most recent.
Temporary residences of less than 90 days may be omitted.
Street

City

State

Zip Code

Time of
Residence

Country

01-2018 to today

Section F: Signature
I declare under penalty of perjury that all statements made in this document are true and correct to the best of my
knowledge.
Signature
DS-5520 xx-xxxx

Date
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