SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE
IDENTITY FOR A U.S. PASSPORT
USE OF SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE IDENTITY FOR A U.S. PASSPORT
This form is intended to supplement an application for a U.S. passport in the event insufficient evidence of identity is provided. In addition to completing this form, you may be asked to provide further documentary evidence to support your identity claim. Documentary evidence should contain your full name/photograph (with issue date) or full name/signature (with issue date). For more information on proof of identity, please refer to page two of the instructions for the DS-11, Application for a U.S. Passport, or visit travel.state.gov.
FORM INSTRUCTIONS
1.To assist us in establishing your identity for a U.S. passport, please fill out this supplemental questionnaire and return it to the requesting passport office. If you have been asked for additional information and/or documentation, please submit the information and/or documentation requested with this supplemental questionnaire.
2.If you are unable to provide primary evidence of identity such as a previously issued U.S. passport, naturalization certificate, valid driver's license, valid government-issued identification or another form of primary evidence of identity, please submit secondary evidence. For lists of primary and secondary evidence of identity, go to http://travel.state.gov/passport and click on the link to information for first time applicants.
3.Please complete the questions on this form to the best of your knowledge. Generally, the more information you are able to provide, the faster we may be able to process your U.S. passport application.
4.If you are unsure of the answer to a question, please provide a response to the best of your knowledge. For example, if you are unsure of an exact address, please provide the city, state and street name if you can recall them. Passport Services will consider all the information derived from the form in its entirety.
5.Failure to answer every question will not necessarily preclude passport issuance, as the form is considered in its entirety.
6.If you have no knowledge of the answer to a question, please write "I don't know." If you believe a particular question does not apply to you or your circumstances, please write "not applicable" or "N/A."
7.If you need more space to respond to a question, please write the rest of your response on a separate sheet of paper.
FOR INFORMATION AND/OR QUESTIONS
Please visit our website at travel.state.gov. In addition, contact the National Passport Information Center (NPIC) toll-free at 1-877-487-2778 (TDD 1-888-874-7793) or by e-mail at NPIC@state.gov. Customer Service Representatives are available Monday-Friday, 8:00 a.m.-10:00 p.m. Eastern Time (excluding federal holidays). Automated information is available 24/7.
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, 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.
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 determine your entitlement to be issued a U.S. passport. The collection of the Social Security number will be used for identity /entitlement to passport verification only and 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 your identity or entitlement, result in processing delays or denial of your passport application.
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time required for searching existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection. Responding to this collection of information is voluntary. 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, D.C. 20520.
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U.S. Department of State
OMB Approval No.: 1405-xxxx
SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE Expiration Date: xx-xx-xxxx
Estimated Burden: 45 minutes
IDENTITY FOR A U.S. PASSPORT
Section A: Biographical Information
1. Full Name:
(First, Middle, Last)
2. Date of Birth: |
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3. Social Security Number:
4. Place of Birth (City, State/Country):
Section B: Information About Your Family (Living and Deceased)
Place of Birth
(City, State, Country)
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Brother |
Joe Smith |
Anytown, |
12-25-1980 |
123 Elm St. Anytown, |
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Anystate, USA |
Anystate |
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Father/Parent
Stepfather/Parent
Mother/Parent
Stepmother/Parent
Sibling
Sibling
Sibling
Sibling
Section C: Employment
Please list your last three places of employment (if applicable)
If self-employed or a contractor working remotely, provide your home addresses.
If active duty military, provide 3 most recent duty stations.
Company Name
Example
ABC
Industries
Address
Example
1001 West Elm Drive
City, State
Example
Anytown, Anystate
Time Employed
Example
2004-2008
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Section D: Schools
Please list all schools that you attended inside and outside of the United States (or as many as possible)
Section E: Residences
Please list your five most recent permanent residences (or as many as possible)
Temporary residences of less than 90 days may be omitted
Time of
Residence
Example
Section F: Signature
I declare under penalty of perjury that all responses contained in this document are true and correct to the best of my knowledge.
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