Change of name affidavits should be submitted with an application for a passport when the name which is used by the applicant is
substantially different from that shown on the evidence of citizenship, or which was not acquired by a female applicant's marriage. The
affiants, preferably blood relatives, must have personal knowledge of the applicant's use of both names.
The applicant may be requested to furnish additional documentation to support the change of name. Final determination as to the name(s)
to be shown in the passport will be made by Passport Services on the basis of the evidence submitted. Completed affidavits will be
retained. Copies should be made at the time of execution.
U.S. Department of State
AFFIDAVIT REGARDING CHANGE OF NAME
(This affidavit need not be presented if a court order documenting a change of name is submitted)
FORMER NAME OF APPLICANT (Or Name Given on Birth Records)
APPROXIMATE DATE PRESENT NAME WAS
NUMBER OF YEARS YOU HAVE KNOWN
APPLICANT'S PLACE OF BIRTH (include city or town)
APPLICANT'S DATE OF BIRTH (mm-dd-yyyy)
NUMBER OF YEARS YOU HAVE KNOWN APPLICANT BY PRESENT
RELATIONSHIP TO APPLICANT (If not related, so state)
; BY FORMER NAME
USE THIS SPACE TO EXPLAIN THE VARIANCE IN THE NAME SHOWN ON BIRTH RECORDS AND THE NAME CURRENTLY USED. STATE WHETHER THE PRESENT NAME IS USED
EXCLUSIVELY FOR ALL PURPOSES OR IS USED AS A "KNOWN AS" NAME.
on reverse, if necessary)
I solemnly swear (or affirm) that the information given by me above is true to the best of my knowledge and belief; that the applicant named above has been known by both his
or her present and former names as stated and is one and the same person; that the applicant is known by his or her present name to friends and relatives, and in the community
in which he or she is residing.
OMB Approval No. 1405-0133
Estimated burden: 15 Minutes*
PRESENT NAME OF APPLICANT (Last, First, Middle)
WARNING: False statements made knowingly and willfully