DS-5513 Supplemental Questionnaire to Determine Entitlement for

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE
ENTITLEMENT FOR A U.S. PASSPORT
USE OF SUPPLEMENTAL QUESTIONNAIRE TO ESTABLISH ENTITLEMENT FOR A U.S. PASSPORT
This form is intended to supplement an application for a U.S. passport in the event insufficient evidence of entitlement is provided. In addition
to completing this form, you may be asked to provide further documentary evidence to support your claim. Documentary evidence should
contain your full name, date and/or place of birth, and the seal or other certification of the issuing office (if customary) and the signature of the
issuing official. For more information on proof of U.S. citizenship, 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 entitlement to 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 U.S. citizenship such as a previously issued U.S. passport or a certified birth
certificate, please submit secondary evidence. For lists of primary and secondary evidence of U.S. citizenship, 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." The Department realizes that most information for this
questionnaire may be difficult to obtain and will likely come from other sources. The Department will take these factors into account in the
passport issuance process.
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 85 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
Expiration Date: xx-xx-xxxx
Estimated Burden: 85 minutes

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE
ENTITLEMENT FOR A U.S. PASSPORT
Section A: Biographical Information
1. Full Name:
(First, Middle, Last)

2. Date of Birth:

-

3. Social Security Number:

-

(month)

(day)

(year)

4. Place of Birth (City, State/Country):

Section B: Information about Your Family (Living and Deceased)
Relationship

Full Name

Place of Birth
(City, State, Country)

Date of Birth

Is This Person
a U.S. Citizen?

Example

Example

Example

Example

Example

Sibling

Joe Smith

Anytown, Anystate, USA

12-25-1980

YES

Father/Parent
Stepfather/Parent
Mother/Parent
Stepmother/Parent
Sibling
Sibling
Sibling
Sibling

Section C: Information for Non-Institutional Births or Delayed Birth Filings
(fill in as much information as possible)
Was your birth recorded within one year of the date your birth occurred?
Were you born in a hospital?

Yes

No

Yes

No

If you answered "No" to either of the above questions, please complete items 1 - 5. Otherwise, please continue on to Section D.

1. List all your parent(s) residences one year before your birth:

(Street Address)

(City)

(State and Country)

(Street Address)

(City)

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(State and Country)

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2. Parent(s) place of employment at the time of your birth:
Dates of employment:

Name of employer:

Address of employer:
(Street Address)

(City)

(State and Country)

Name of employer:

Dates of employment:
Address of employer:

(Street Address)

(City)

(State and Country)

3. If your parents were not U.S. citizens at the time of your birth, what type of document, if any, did they use to enter the
United States? Examples include foreign passport, U.S. or a foreign border crossing document, residency card, etc.

4. Mother's medical information:
Did your mother receive medical care while pregnant with you and/or up to one year after your birth?

Yes

No

Name of hospital or other facility:

Address:
(Street Address)

No
(City)

(State and Country)

Name of Doctor:
Approximate dates of appointments:

Please provide description of birthing location:
(Private home, hospital, clinic, etc.)

Length of time mother stayed at the birthing location listed above?
(One day, three weeks, etc.)

Please provide the names (as well as address and phone number, if available) of persons present at your birth such as
medical personnel, family members, etc:

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Section D: Schools/Day Care Centers/Developmental Programs
Please list any schools, day care centers, or developmental programs you attended from birth to age 18 in or outside of the
United States (list at least the first three or as many as possible).
Name of School/Daycare/ Developmental Program

City

State

Country

Dates of Attendance

Example

Example

Example

Example

Example

Washington Elementary

Anytown

Anystate

USA

08-1990 to
06-1994

Section E: Residences
Please list all of your permanent residences inside and outside of the United States starting with your birth until age 18
(list at least the first three or as many as possible). Temporary locations of less than 90 days may be omitted.
Street

City

State

Country

Time of

Example

Example

Example

Example

Example

123 First St.

Anytown

Anystate

USA

03-1990 to
06-2002

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.

Signature
DS-5513 07-2013

Date
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