Form DS-0071 AFFIDAVIT OF IDENTIFYING WITNESS

U.S. Department of State

OMB CONTROL NO. 1405-0088
OMB EXPIRATION DATE: xx-xx-xxxx
ESTIMATED BURDEN: 5 MIN

AFFIDAVIT OF IDENTIFYING WITNESS
IDENTIFICATION OF A PASSPORT APPLICANT

This form should be completed ONLY by the identifying witness and is to ONLY be
used in conjunction with form DS-11, Application for a U.S. Passport.
1. Passport Applicant's Name (Last, First, Middle)

2. How do you (the Witness) know the passport applicant?
3. How long have you (the Witness) known the passport applicant?
Months

Years

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

5. Witness' Residential Address
City, State, ZIP Code
6. Witness' Place of Birth (City, State)

9. Witness' Telephone Number

7. Witness' Date of Birth (mm-dd-yyyy)

9. Witness' Social Security Number

10. Have you (the Witness) ever been issued a U.S. Passport?
No

Yes
11. Witness' Passport Number

If yes, continue with questions 11 - 12

12. Date of Issue (mm-dd-yyyy). If unknown, give approximate date.

STOP! DO NOT SIGN THE AFFIDAVIT UNLESS REQUESTED TO DO SO BY
AN AUTHORIZED ACCEPTANCE AGENT
NOTE TO THE WITNESS: You must include a photocopy of the front and back of your photo identification.
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.
Date (mm-dd-yyyy)

Signature

FOR ACCEPTANCE AGENT'S USE ONLY
Subscribed and sworn to (affirmed) before me

Acceptance Agent
(Seal)

Signature

Passport Staff Agent
(Vice) Consul USA

Location

Date (mm-dd-yyyy)

WITNESS' PRIMARY 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)

WITNESS' SECONDARY 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 xx-xxxx

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USE OF AFFIDAVIT OF IDENTIFYING WITNESS
This form may be submitted with a passport application when the passport applicant is unable to establish his or her identity to the satisfaction of the
authorized acceptance agent. The passport applicant must still present some identification of his or her own. You, the witness, must complete items
one through ten (and if applicable, 11 through 12) of this form, 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 your own. You must include a photocopy of the front
and back of your identification.

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
U.S. 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
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 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 the applicant's entitlement to a U.S. passport. The collection of the Social
Security number will be used to verify the identity of you, the witness, 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
Other Overseas Records, and State-26, Passport Records.
DISCLOSURE: Providing your Social Security number and other information on this form is voluntary. Given the form's purpose of verification of
identity and entitlement to a U.S. passport, failure to provide the information may 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 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, 44132 Mercure Cir, P.O. Box 1199, Sterling, VA 20166-1199.
DS-71 xx-xxxx

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