DEPARTMENT OF
STATE |
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| Change of name affidavits should be submitted with an application for a passport when the name which is used by the applicant is substantially different from that shown on the evidence of citizenship, or which was not acquired by a female applicant's marriage. The affiants, preferably blood relatives, must have personal knowledge of the applicant's use of both names.The applicant may be requested to furnish additional documentation to support the change of name. Final determination as to the name(s) to be shown in the passport will be made by the Passport Office on the basis of the evidence submitted. Completed affidavits will be retained. Copies should be made at the time of execution. | |
| Name of Applicant |
Approximate Date Present Name was Assumed |
| Former Name of Applicant (or name given on birth records) | Number of Years
You Have Known Applicant
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| Applicant's Place
of Birth (include city of town) |
Applicant's Date
of Birth (month,day,year)
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| Number of Years
You Have Known Applicant ________ : by former name _________ (years) (years) |
Relationship to
Applicant (if not related, so state)
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| USE THIS SPACE TO EXPLAIN THE
VARIANCE IN THE NAME SHOWN ON BIRTH RECORDS AND THE NAME PRESENTLY USED. STATE WHETHER THE
PRESENT NAME IS USED EXCLUSIVELY FOR ALL PURPOSES OR IS USED AS A "KNOWN AS"
NAME. (Continue on reverse, if necessary) |
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| NOTE: A severe penalty is
provided in Title 18, Section 1542, United States Code, for the falsification of
applications for passports, or of affidavits or other documents to be used in connection therewith. |
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| 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, and 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. | |
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I solemnly swear (or affirm) that the information given
by me above is true to the best of my knowledge and belief; that the
applicant named above has been known by both his/her present and former
names as stated and is one and the same person; that the applicant is
known by his/her present name to friends and relatives, and in the community
in which he/she is residing.
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