Form DS-5507 AFFIDAVIT OF PHYSICAL PRESENCE OR RESIDENCE, PARENTAGE A

U. S. Department of State

AFFIDAVIT OF PHYSICAL PRESENCE OR RESIDENCE,
PARENTAGE AND SUPPORT

OMB CONTROL NO. 1405-0187
EXPIRES - XX-XX-20XX
Estimated Burden - 30 minutes

It is not expected that a transmitting U.S. citizen parent who completes the DS-2029 would also be required to complete this form.

PART I
(All affiants please complete Part I)
I,

do solemnly swear (or affirm):
Name
That I am a U.S. citizen/U.S. non-citizen national by: (choose one)

1) birth in

on
City/Town, State in the United States

2) naturalization on

3) birth abroad on

before the
Date (mm-dd-yyyy)
Name of Court or USCIS Office and U.S. State

to U.S. citizen(s) or U.S. non-citizen national(s) in
Date (mm-dd-yyyy)
Country

That I am (choose all that apply)
married on

Date (mm-dd-yyyy)

Married

Previously Married

Single

to
Date (mm-dd-yyyy)

in

Name
If terminated, list date and manner of termination (e.g. death or divorce) or enter N/A.

Country
(Please use a separate sheet to list additional marriages and marriage termination information.)

That I am the biological parent of:
Name of Child

Date of Birth
(mm-dd-yyyy)

Place of Birth

(Continue on a separate sheet, if necessary)

DS-5507
10-2018

(Continued on the next page)

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That I have been physically present or have had a residence in the United States as follows:

Place (City, State)

Date
(mm-dd-yyyy)

Date
(mm-dd-yyyy)

From

To

From

To

From

To

From

To

From

To

Purpose
(Indicate purpose(s) of stay: vacation, family visit,
business trip, studies, employment, residence, etc.)

(Continue on a separate sheet, if
Note: If claiming a residence in the United States during any of the above periods, please also provide in the Place block above
the address (street and house or apartment number) in which this was your principal actual dwelling place (place of general
abode). You may be asked to provide supporting evidence with respect to your residential address. Examples of documents that
can help demonstrate residence include, but are not limited to: property rental leases and payment receipts; deeds; utility bills;
property tax records; automobile registrations; professional licenses; employment records or information; income tax records;
stamped school transcripts; military records; income records, including W-2 salary forms; vaccination and medical records.
That I have been physically present or have had a residence
abroad as follows:
Place (City, Country)

Date
(mm-dd-yyyy)

Date
(mm-dd-yyyy)

From

To

From

To

From

To

From

To

Purpose
(Indicate purpose(s) of stay: vacation, family visit,
business trip, studies, employment, residence, etc.
If working abroad, provide the name of employer.
Specify if in U.S. government employment or
military service or on orders as a dependent.)

(Continue on a separate sheet, if necessary)
That the other biological parent of the above-named child/children for whom this application for a Consular Report of Birth
and/or U.S. passport is being filed is:

Name
is a citizen or national of the U.S.
is not a citizen of the U.S.

If the other parent is a U.S. citizen/U.S. non-citizen national it is by:
1) birth in

on
City/Town, State in the United States

2) naturalization on

before the
Date (mm-dd-yyyy)

3) birth abroad on

DS-5507

Date (mm-dd-yyyy)

Name of Court or USCIS Office and U.S. State

to U.S. citizen(s)/U.S. non-citizen national(s) in
Date (mm-dd-yyyy)
Country

(Continued on the next page)

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The other biological parent has been physically present or has had a residence in the United States as follows: (PROVIDE ONLY IF THE
OTHER PARENT IS A U.S. CITIZEN OR U.S. NON-CITIZEN NATIONAL)

Place (City, State)

Date
(mm-dd-yyyy)

Date
(mm-dd-yyyy)

From

To

From

To

From

To

From

To

From

To

From

To

Purpose
(Indicate purpose(s) of stay: vacation, family visit,
business trip, studies, employment, residence, etc.)

(See Note on previous page about Address information to be provided if claiming a residence in the United States. Continue on a
separate sheet, if necessary)

PART II
(All U.S. National Fathers of a Child Born Abroad Out of Wedlock)

PLEASE STOP HERE! Part II of this document must be signed before a Consular Officer, Passport Specialist, or designated
Consular/Acceptance Agent at the time the oath is sworn.
I am the biological father through whom such child is claiming U.S. citizenship. I agree to provide financial support for such child until
he/she reaches the age of eighteen years.

Signature of Affiant
Subscribed and sworn before me this

day of

,

.

[SEAL]
Signature and Title of Consular Officer, Passport
Specialist or designated Consular/Acceptance
Agent Administering Oath

DS-5507

(Continued on the next page)

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PART III
(Oath: To be completed by all affiants)
PLEASE STOP HERE. Part III of the document must be signed before a Consular Officer, Passport Specialist, or designated
Consular/Acceptance Agent at the time the oath is sworn.
WARNING: False statements made knowingly and willfully in applications for citizenship documentation or affidavits and other supporting
documents are punishable by fine and/or imprisonment under the provisions of 18 USC 1001 and other applicable criminal statutes.
A U.S. Consular Officer or Passport Specialist may require additional evidence of one's biological relationship to one's child and/or evidence
of one's physical presence or residence in the United States.
I solemnly swear (or affirm) that all the statements contained in this affidavit are true and complete to the best of my knowledge and belief,
and that this affidavit is for the purpose of establishing my relationship to the aforementioned child/children and his/her/their claim to U.S.
citizenship.

Signature of affiant

Present Street Address

State

City

Zip Code

Country

Telephone Number

SUBSCRIBED AND SWORN TO (AFFIRMED) before me this
at

day of

,

,

,
[SEAL]

Signature and Title of Administering Officer

DS-5507

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PRIVACY ACT STATEMENT
AUTHORITY: The Department of State is authorized to collect this information pursuant
to 8 U.S.C. §§ 1104(a), 1401, 1408 and 1409, and 22 U.S.C. §§ 211a, 213 and 2705.
PURPOSE: The principal purpose of the information gathered is to assist in
determining whether a U.S. national biological parent of a child born abroad or in a
United States territory has met the statutory physical presence or residence
requirements for his or her child to acquire U.S. nationality at birth; and whether a U.S.
national father of a child born abroad out of wedlock has met additional requirements of
8 U.S.C. § 1409(a) in relation to biological parentage and legal relationship with and
financial support of his child born abroad out of wedlock, in order for such child to
acquire U.S. citizenship at birth.
ROUTINE USES: The information solicited on this form may be made available to
Federal government entities such as the Social Security Administration, the Department
of Homeland Security, and Department of Justice, in connection with determinations of
citizenship status, administration of federal benefits, and law enforcement purposes as
set forth in the System of Records Notices for Overseas Citizens Services Records and
Other Overseas Records, State-05, 81 FR 62235-62239 (2016); Passport Records,
State-26, 80 FR 15653 (2015); and the Department-wide Prefatory Statement of Routine
Uses, 73 FR 40649-40651 (2008). Information also can be made available to appropriate
federal, state, local or foreign government entities, such as state law enforcement
agencies, state prosecutors, judicial staff, and Interpol, in connection with law
enforcement, safety, welfare and related matters, as set forth in the aforementioned
System of Records Notices.
Furnishing the information on this form is voluntary; however, failure to furnish the
requested information may delay or prevent you from documenting your child as a U.S.

PAPERWORK REDUCTION ACT (PRA) STATEMENT
Public reporting burden for this collection of information is estimated to average 30
minutes per response, including time required for searching existing data sources,
gathering the necessary documentation, 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: CA/OCS/PMO, 10th Floor, SA-17, U.S. Department of
State, Washington, DC 20522-1710.

DS-5507

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