Affidavit Regarding A Change Of Name {DS-60}

U.S. Department of State AFFIDAVIT REGARDING A CHANGE OF NAME Please Print Legibly Using Black Ink Only. OMB APPROVAL NO. 1405-0133 EXPIRES: 09-30-2017 ESTIMATED BURDEN: 40 MINUTES WARNING False statements made knowingly and willfully on passport applications or on affidavits or other supporting documents submitted therewith are punishable by fine and/or imprisonment under 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 therein 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. PURPOSE An Affidavit Regarding a Change of Name may be submitted with an application for a U.S. passport when the name which is used by the applicant is (1) substantially different from that shown on the evidence of citizenship or (2) has been adopted without formal court proceedings and was not acquired by a marriage. The affiant (preferably a blood relative) must have personal knowledge of the applicant's use of both names. To support a change of name that has been adopted without formal court proceedings or by a marriage, the applicant must present original or certified copies of three or more public documents evidencing that the applicant has used the acquired name generally for five years or longer. Affidavits Regarding a Change of Name from at least two persons, attesting that they have known the applicant by both names and that the applicant has used the new name generally for at least five years, may be provided in place of one of the public documents if the applicant cannot obtain a third public document. The affidavit must be accompanied by a photocopy of the front and back of the affiant's identification. Final determination of the name(s) to be shown in the U.S. passport will be made by Passport Services based on all submitted evidence. Completed affidavits will be retained and requests for copies of this affidavit should be made at the time of execution. An affidavit does not need to be submitted if an applicant can present a court order documenting the change of their name. 1. Current Name of Applicant Last First 2. Approximate Date Current Name Was Assumed (mm-yyyy) Suffix (Jr.,Sr.,III) Middle 3. Former Name of Applicant (or Name Given on Birth Records) Last First 4. Applicant's Date of Birth (mm-dd-yyyy) Suffix (Jr.,Sr.,III) Middle 5. Applicant's Place of Birth (City and State) 6. Number of Years You Have Known the Applicant By Current Name By Former Name 7. Your Relationship to the Applicant Explain the variance in the applicant's name shown on his/her birth records and the name currently used. State whether the current name is used exclusively and for all purposes or if it is used as an "also known as" name. Continue on the back of this form if additional space is required. I solemnly swear (or affirm) that the information given above by me is true and correct to the best of my knowledge and belief; that the applicant named above has been known by both his or her present and former names as stated and is one and the same person; that the applicant is known by his or her present name to friends and relatives, and in the community in which he or she is residing. Printed Name of Affiant Signature of Affiant Affiant's Social Security Number (SEAL) Address of Affiant (Number and Street, City, State, and Zip Code ) Identifying Document Submitted (Type of Document, Date of Issuance and/or Expiration, Document Number) Subscribed and Sworn to (Affirmed) before me this day of at Name of Passport Agent, Acceptance Agent, or Notary Public DS-60 01-2014 American LegalNet, Inc. www.FormsWorkFlow.com Location (Passport Agency or City and State) Page 1 of 2 For Additional Comments PRIVACY ACT STATEMENT AUTHORITIES: We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 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 establish the identity ofthe subject of this affidavit as part of the subject's application for a U.S. passport. The collection of the Social Security number will be used to verify your identity and for 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 State-26, Passport Records. DISCLOSURE: Providing your Social Security number and the other information on this form is voluntary, but failure to provide the information on this form may, given the form's purpose of verification of identity and entitlement to a U.S. passport, result in processing delays or denial of the passport application. PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is estimated to average 40 minutes per response, including the time required for searching existing data sources, gathering the necessary data, providing the information and/or documentation 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: Passport Forms Management Officer, U.S. Department of State, Office of Program Management and Operational Support, 2201 C Street N.W., Washington, DC 20520. DS-60 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com