Form DS-5513 Supplemental Questionnaire to Determine Entitlement for

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE
ENTITLEMENT 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 entitlement is provided. In addition
to completing this form, you may be asked to provide further documentary evidence to support your citizenship claim. Documentary evidence
should contain your full name, date and/or place of birth, the seal or other certification of the issuing office (if customary), and the signature of
the issuing offical. For more information on proof of U.S. citizenship, please refer to Instruction pages 1 and 2 of the DS-11, Application for a
U.S. Passport, or visit travel.state.gov/citizenship.

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 appliction. 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 U.S. citizenship, such as a previously-issued U.S. passport or a certified birth certificate,
please submit secondary evidence. For lists of primary and secondary evidence of U.S. citizenship, go to travel.state.gov/citizenship.
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.

INFORMATION
AND/OR
QUESTIONS
5. If you need more space to respond to aFOR
question,
please write the rest
of your responses
on a separate piece 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 85 minutes per response, including the 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, Virginia, 20166-1199.
DS-5513 xx-xxxx

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U.S. Department of State

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

OMB CONTROL NO. 1405-0214
OMB EXPIRATION DATE: xx-xx-xxxx
ESTIMATED BURDEN: 85 minutes

Section A: Biographical Information
1. Full Name:

(First, Middle, Last)

2. Date of Birth:

-

(mm-dd-yyyy)

-

3. Social Security Number:

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.)
Full Name
(Include maiden name, if applicable)

Relationship

Brother

Joe Smith Keaton

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

Anytown, Anystate, USA

Date of Birth

12-25-1980

Stepparent(s)

Sister(s)/
Brother(s)

X

Yes
No
Yes

1.

Parent(s)

U.S.
Citizen?

No

2.

Yes
No

1.

Yes
No

2.

Yes
No

1.

Yes
No

2.

Yes
No

3.

Yes
No

4.

Yes
No

1.

Yes
No

2.

Yes
No

3.

Yes
No

4.

Yes
No

Grandparent(s)

List name changes for any of your relatives above. For example, “Mother’s maiden name -- Jane Johnson”:

Section C: Information for Non-Institutional Births or Delayed Birth Filings
(Fill in as much information as possible. Attach a separate sheet, if needed.)

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

Yes

No

Name of medical professional:
Approximate dates of appointments:
DS-5513 xx-xxxx

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Mother's medical information (continued):
Name of hospitals or facilities where she received care during pregnancy:

Address:

(Street Address)

No
(State and Country)

(City)

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.:

2. 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, legal permanent resident
card, etc.?

3. List all your parents' residences one year before your birth (Attach a separate sheet, if needed.):
(Street Address)

(City)

(State and Country)

(Street Address)

(City)

(State and Country)

4. List your parents' place(s) of employment at the time of your birth:
Dates of employment:

Name of employer:

Address of employer:
(Street Address)

(City)

Dates of employment:

(State and Country)

Name of employer:

Address of employer:
(Street Address)

(City)

DS-5513

(State and Country)

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Section D: Schools/Day Care Centers/Developmental Programs
(Fill in as much information as possible. Attach a separate sheet, if needed.)

Please list any schools, day care centers, or developmental programs you attended from birth to age 18, inside or outside of the
United States starting with the first three you attended.
List the institutions below and submit documents as available.
.

City

Name of School/Day Care/ Developmental Program

Washington Elementary

Anytown

State

Country

Anystate

USA

Dates of Attendance

08-1990 to 06-1994

Section E: Residences
(Fill in as much information as possible. Attach a separate sheet, if needed.)
Please list all of your residences, inside and outside of the United States, from birth to age 18, starting with your first three.

Street

City

State

Country

123 First St.

Anytown

Anystate

USA

Time of
Residence

03-1990 to
06-2002

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-5513 xx-xxxx

Date
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