UNITED STATES DEPARTMENT OF STATE
BIRTH AFFIDAVIT
Completed affidavits will be retained by the Pssport Office. Copies desired should be made at the time of execution.
When an acceptable birth certificate cannot be obtained for a person born in the United States, a birth affidavit, accompanied by a notice from appropriate authorities indicating no birth record exists, may be submitted with an application for a passport. The birth affidavit form may also be submitted in conjunction with other birth records. The birth affidavit should be made by a person who has knowledge of the date and place of birth of the person whose birth in the United States is to be proved. The affidavit shall state briefly how and through what source the knowledge was acquired. It is preferred that the affidavit be made by an older blood relative although it may be made by the attending physician or any other person who has personal knowledge of the birth.
NAME OF PERSON WHOSE BIRTH IN THE UNITED STATES IS TO BE PROVED

 Sex:
   (   )     Male   
  (   )    Female  		 NUMBER OF YEARS YOU HAVE KNOWN THIS PERSON
PERSON'S PLACE OF BIRTH (City and State)

 PERSON'S DATE OF BIRTH (Month, day, year)
PERSON'S PRESENT RESIDENCE (Street address, City, State and ZIP code) IF DECEASED, SO STATE:

 RELATIONSHIP TO OR BASIS OF YOUR KNOWLEDGE REGARDING THIS PERSON
GIVE COMPLETE FACTS ON WHICH THE PLACE AND DATE OF BIRTH ARE BASED. IF AFFIANT IS NOT CLOSELY RELATED TO PERSON WHOSE BIRTH IN THE U.S. IS TO BE PROVED, STATE HOW AND THROUGH WHAT SOURCE THE PERSONAL KNOWLEDGE WAS ACQUIRED (Continue on reverse, if necessary)
NOTE: A severe penalty is provided in Title l8 Section 1542, United States Code for the falsification of applications for passports,or of affidavits or other documents to be used in connection therewith.
PRIVACY ACT STATEMENT
The information solicited on this form is authorized by, but not limited to, those statutes codified in Titles 8,18, and 22, United States Code, and all predecessor statutes whether or not codified, and all  regulations issued pursuant to Executive Order 11295 of August 5,1966. The primary purpose for soliciting the information is to establish citizenship, identity and entitlement to issuance of a United States passport or related facility, and to properly administer and enforce the laws pertaining thereto.
The information is made available as a routine use on a need-to-know basis to personnel of the Department of State and other government agencies having statutory or other lawful authority to maintain such information in the performance of their official duties; pursuant to a subpoena or court order; and, as set forth in Part 6a, Title 22, Code of Federal Regulations.
(See Federal Register, Volume 40, pages 45755,45756,47419, & 47420.) Failure to provide the information requested on this form may result in the denial of a United States passport, related document or service to the individual seeking such passport, document or service.

   I, the undersigned, do solemnly swear (or affirm) that the above information given by me is true and correct to the best of my knowledge and belief.



___________________________________________________________________________________________________
(printed or typed name of affiant)                                                               Signature of affiant


                     (impression seal)                                   ________________________________________________________
                                                                                          address of affiant: number,street,city, state, & zip


                                                                                       ________________________________________________________
                                                                           (identifying document submitted by affiant: type, date, expiration, serial number


   Subscribed and sworn to (affirmed) before me this________________day of___________________,19____


____________________________________________________at______________________________________________
(Passport Agent, Postal Employee, Clerk of Court, or Notary Public

FORM DSP-10A

 

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