Form DS-60 Affidavit Regarding a Change of Name

U.S. Department of State

AFFIDAVIT REGARDING A CHANGE OF NAME

OMB APPROVAL NO. 1405-0133
EXPIRES: xx-xx-xxxx
ESTIMATED BURDEN: 15 MINUTES*

WARNING False statements made knowingly and willfully in passport applications or in affidavits or other supporting documents submitted
therewith are punishable by fine and/or imprisonment under the provisions of 18 U.S.C. 1001 and/or 18 U.S.C. 1542. 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 and/or (2) has been adopted without formal court proceedings
and was not acquired by a marriage or under operation of state law. 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 three or more public documents showing exclusive use of the name for a long period of time, generally five years. 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
for all purposes for five years may be provided in place of one of the public documents if the applicant cannot obtain a third public document. Final
determination of the name(s) to be shown in the U.S. passport will be made by Passport Services based on all of the evidence submitted. 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
Title (Jr.,Sr.,III)
Middle

Last
First

2. Approximate Date Current Name Was Assumed (mm-dd-yyyy) 3. Number of Years You Have Known the Applicant
4. Former Name of Applicant (or Name Given on Birth Records)
Last

Title

First

Middle

5. Applicant's Date of Birth (mm-dd-yyyy)

6. Applicant's Place of Birth (City and State)

7. Number of Years You Have Known the Applicant
By Current Name

(Jr.,Sr.,III)

8. Your Relationship to the Applicant

By Former Name

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
(SEAL)

Address of Affiant (Number and Street, City, State, and Zip Code )
Identifying Document Submitted (Type of Document, Date of Issuance/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
xx-xxxx

Location (Passport Agency or City and State)
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For Additional Comments

PRIVACY ACT STATEMENT
AUTHORITIES: The information solicited on this form is requested pursuant to provisions in Titles 8 and 22 of the
United States Code (U.S.C.), whether or not codified including specifically 22

U.S.C. 211a, 212, 213, and all

regulations issued pursuant to Executive Order 11295 (August .5, 1966), including Part 51, Title 22, Code of Federal
Regulations (CFR).

PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to
the issuance of a U.S. passport. The information may also be used in connection with issuing other travel documents
or evidence of citizenship, and in furtherance of the Secretary of State's responsibility for the protection of U.S.
nationals abroad.

ROUTINE USES: The information solicited on this form may be made available as a routine use to other
government agencies (such as the FBI, DHS, etc.), to assist the U.S. Department of State in adjudicating passport
applications and requests for related services, and for law enforcement and administrative purposes. It may also be
disclosed pursuant to court order. The information may be made available to foreign government agencies to fulfill
passport control and immigration duties or to investigate or prosecute violations of law. The information may also be
made available to private U.S. citizen 'wardens' designated by U.S. embassies and consulates for use in emergency
evacuation or other appropriate situations.
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.

PAPERWORK REDUCTION ACT STATEMENT

*Public reporting burden for this collection of information is estimated to average 15 minutes per response, including
time required for searching existing data sources, gathering the necessary data, providing the information required,
and reviewing the final collection. You are not required to respond to the collection of information unless this form
displays a currently valid OMB number. Send comments on the accuracy of this estimate of the burden and
recommendations for reducing it to: U.S. Department of State (A/ISS/DIR) Washington, DC 20520.

DS-60

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