DS-5513 Supplemental Questionnaire to Determine Entitlement for

U.S. Department of State

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE ENTITLEMENT
FOR A U.S. PASSPORT

OMB CONTROL NO. 1405-0214
Expiration Date: XX/XX/20XX
Estimated Burden: 85 minutes

Please Print Legibly Using Black Ink Only

3/($6('212786(7+,6)25081/(667+('(3$570(172)67$7($6.6<287286(,7

USE OF THIS FORM

This form is completed by the applicant only when specifically requested by a passport agency/center when sufficient evidence of entitlement is
needed to process your application for a U.S. passport. The applicant has the option to complete the hardcopy form enclosed with the letter
from the passport agency/center or complete a fillable PDF version of the form available from a link as provided in the written request. Please
Note: You must print out the form and submit a hardcopy through the mail to the passport agency/center. You may not submit this
form electronically. In addition to completing this form, you may be asked to provide further documentary evidence to support your citizenship
claim. Documentary evidence should contain your full name, date and/or place of birth, 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 Instruction pages 1 and 2
of the DS-11, Application for a U.S. Passport, or visit travel.state.gov/citizenship.

IMPORTANT
1.
2.
3.
4.

5.

All questions must be answered to the best of your knowledge. The more information you are able to provide, the faster we may be
able to process your U.S. passport application. For example, if you are unsure of an exact address, please provide the street, city, and
state if you can recall them. The Department of State will consider all the information derived from the form in its entirety.
Please submit the information and/or documentation requested with this supplemental questionnaire to the requesting passport
agency/center.
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 travel.state.gov/citizenship.
If you don’t know 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.
If you need more space to respond to a question, please write the rest of your responses on a separate piece of paper.

FOR INFORMATION AND/OR QUESTIONS
For passport and travel information, please visit travel.state.gov. In addition, contact the National Passport Information Center (NPIC) toll-free at
1-877-487-2778 (TDD/TTY 1-888-874-7793) or by email at NPIC@state.gov.

WARNING
False statements made knowingly and willfully in passport applications, including affidavits or other documents submitted to support this
application, are punishable by fine and/or imprisonment under U.S. law including 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 herein 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. Failure to provide information
requested on this form, including your Social Security number, may result in significant processing delays and/or the denial of your
application.

PRIVACY ACT STATEMENT
AUTHORITIES: Collection of this information is authorized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 22 U.S.C. 2714a(f); 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 Other Overseas
Records and State-26, Passport Records.
DISCLOSURE: Providing information on this form is voluntary. Be advised, however, that failure to provide the information requested on this
form may cause delays in processing your U.S. passport application and/or could result in the refusal or denial of your application. Failure to
provide your Social Security number may result in the denial of your application (consistent with 22 U.S.C. 2714a(f)) and may subject you to a
penalty enforced by the Internal Revenue Service, as described in the Warning section of the instructions to this form. Your social security
number will be provided to the Department of the Treasury and may be used in connection with debt collection, among other purposes
authorized and generally described in this section.

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. 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 Circle, PO Box 1199,
Sterling, Virginia, 20166-1199.

DS-5513 XX-20XX

Page 1 of 3

U.S. Department of State

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE ENTITLEMENT
FOR A U.S. PASSPORT

OMB CONTROL NO. 1405-0214
Expiration Date: XX/XX/20XX
Estimated Burden: 85 minutes

RESET

Please Print Legibly Using Black Ink Only

3/($6('212786(7+,6)25081/(667+('(3$570(172)67$7($6.6<287286(,7

Section A: Biographical Information
1. Full Name:

First

Middle

2. Date of Birth:

-

(mm-dd-yyyy)

4. Place of Birth:

Last

3. Social Security Number:

-

U.S. City & State or City & Country

Section B: Family (Living and Deceased)

(Fill in as much information as possible. Attach a separate sheet, if needed.)

Relationship

(Include maiden name, if applicable)

Full Name

(U.S. City & State or City & Country)

Place of Birth

Date of Birth

Joe Smith Keaton

Anytown, Anystate, USA

12-25-1980

Brother
1. Parent(s)

(mm-dd-yyyy)

1.
2.

2. Stepparent(s)

1.
2.
1.

3. Sister(s)/
Brother(s)

2.
3.
4.
1.

4. Grandparent(s)

2.
3.

4.
5. List name changes for any of your relatives above. For example, “Mother’s maiden name -- Jane Johnson”:

U.S.
Citizen?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Section C Information for Non-Institutional Births or Delayed Birth Filings
(Fill in as much information as possible. Attach a separate sheet, if needed.)

1. Mother's medical information:

a. Did your mother receive medical care while pregnant with you and/or up to one year after your birth?

Yes

No

b. Name of medical professional:
c. Approximate dates of appointments:
d. Name of hospitals or facilities where she
received care during pregnancy:
e. Hospital or Facility Address:

Street

City

State and Country

f. Please provide description of birthing location
(Private home, hospital, clinic, etc.):
g. Length of time mother stayed at the birthing
location listed above? (One day, three weeks, etc.)
h. 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.:

DS-5513 XX-20XX

Page 2 of 3

U.S. Department of State

SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE ENTITLEMENT
FOR A U.S. PASSPORT

OMB CONTROL NO. 1405-0214
Expiration Date: XX/XX/20XX
Estimated Burden: 85 minutes

Please Print Legibly Using Black Ink Only

3/($6('212786(7+,6)25081/(667+('(3$570(172)67$7($6.6<287286(,7
2. 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, legal permanent resident
card, etc.?

3. List all your parents' residences one year before your birth (Attach a separate sheet, if needed.):
Street Address

City

State and Country

Street Address

City

State and Country

Street Address

City

State and Country

4. List your parents' place(s) of employment at the time of your birth:
Employment Dates:

Employer’s Name:

Employer’s Street Address

City

Employment Dates:

Employer’s Name:

Employer’s Street Address

City

State and Country

State and Country

Section D: Schools/Day Care Centers/Developmental Programs
(Fill in as much information as possible. Attach a separate sheet, if needed.)

1. Please list any schools, day care centers, or developmental programs you attended from birth to age 18, inside or outside of the United
States starting with the first three you attended. List the institutions below and submit documents as available.
Name of School/Day Care/ Developmental Program

City

State

Country

Dates of Attendance

Washington Elementary

Anytown

Anystate

USA

08-1990 to 06-1994

Section E: Residences

(Fill in as much information as possible. Attach a separate sheet, if needed.)
1. Please list all of your residences, inside and outside of the United States, from birth to age 18, starting with your first three.
Street

City

State

Country

Time of Residence

123 First St.

Anytown

Anystate

USA

03-1990 to 06-2002

Section F: Signature
I declare under penalty of perjury that all statements made in this document are true and correct to the best of my knowledge.
Signature
DS-5513 XX-20XX

Date
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