Form Ds 71 – Fill Out and Use This PDF

1. Passport Applicant's Name (Last, First, Middle)

2. Basis of your knowledge concerning the Passport Applicant (Such as your relationship to the applicant)

3. How long have you (THE WITNESS) known the Passport Applicant?

YearsMonths

WITNESS INFORMATION

4. WITNESS' Name (Last, First, Middle)

5. WITNESS' Residential Address

	City, State, ZIP Code
6.	WITNESS' Place of Birth (City, State, Zip Code)					7. WITNESS Date of Birth (mm-dd-yyyy)
8.	WITNESS Daytime Telephone Number			9. WITNESS Home Telephone Number		10. Have you as the WITNESS been issued a U.S.
						Passport?	Yes	No
	(	)		(	)	If yes, continue with questions #11 - 13.
11. WITNESS Passport Number				12. Place of Issue if Known		13. Date of Issue	(mm-dd-yyyy) If necessary, give
						approximate.
NOTE: Read the following oath but			DO NOT SIGN the affidavit until requested to do so by an Authorized Acceptance

Agent.

I declare under penalty of perjury that I know or have reason to believe the above-named passport applicant is a citizen or non-citizen national of the United States; and the above statements are true and correct.

SignatureDate (mm-dd-yyyy)

FOR ACCEPTANCE AGENT'S USE ONLY

Subscribed and sworn to (affirmed) before me

(Seal)

Clerk of Court

Signature

Passport Agent

Location

Postal Employee

(Vice) Consul USA

Date

(mm-dd-yyyy)

APPLICANT'S IDENTIFICATION

1. Issued in the Name of

Type of Document

Document Number

Place of Issue

Date of Issue (mm-dd-yyyy)

Date of Expiration (mm-dd-yyyy)

2. Issued in the Name of

Type of Document

Document Number

Place of Issue

Date of Issue (mm-dd-yyyy)

Date of Expiration (mm-dd-yyyy)

WITNESS' IDENTIFICATION

Issued in the Name of

Type of Document

Document Number

Place of Issue

Date of Issue (mm-dd-yyyy)

Date of Expiration (mm-dd-yyyy)

DS-71	Page 1 of 2
05-2009

USE OF THE AFFIDAVIT OF IDENTIFYING WITNESS: This affidavit is required to be included with a passport application only when the applicant for a passport is unable to establish his or her identity to the satisfaction of a person authorized to accept passport applications. The applicant must still present some identification of his or her own. Witnesses must complete items one through ten (and if applicable, eleven through thirteen), sign when requested to do so by the same authorized acceptance agent who accepted the passport application, and present some form of current photo identification of his or her own.

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 provisions of 18 U.S.C. 1001 and/or 18 U.S.C. 1542. Alteration or mutilation of a U.S. passport is punishable by fine and/or imprisonment under provisions of 18 U.S.C. 1543. The use of a U.S. 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 submitted are subject to verification.

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS

AUTHORITIES: The information solicited on this form may be requested pursuant to provisions in Titles 8 and 22 of the United States Code (U.S.C.), including specifically 22 U.S.C. 211A, et seq., and all regulations issued pursuant to Executive Order 11295 (August 5, 1966), including Part 51, Title 22, Code of Federal Regulations (CFR), and in particular 22 CFR 51.41 and 51.45.

The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to 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'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, 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.

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Failure to provide the information

requested on this form may result in the denial of a United States passport, related documents, or service to the individual seeking such passport, documents, or service.

*Public reporting burden for this collection of information is estimated to average 5 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: U.S. Department of State, Bureau of Consular Affairs, Passport Services, Office of Program Management and Operational Support, 2201 C Street, NW, Washington, DC 20520.

DS-71

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