I, ................................................., do solemnly swear (or affirm):
That I am an American citizen by: (choose one)
1) birth in (city/town, state) .....................................................
on (date) ...................................................
2) naturalization on (date) .................................
before the (name of court) ................................................................
3) birth abroad on (date) ............................. to American parent(s)
That I have been physically present in the United States as follows:
PLACE (CITY, STATE) DATE (MONTH/DAY/YEAR) DATE (MONTH/DAY/YEAR)
................................. From ....................... To ...............................
................................. From ....................... To ...............................
................................. From ....................... To ...............................
................................. From ....................... To ...............................
................................. From ....................... To ...............................
................................. From ....................... To ...............................
(Continue on separate sheet, if necessary.)
That I have been physically present abroad as follows:
PLACE (CITY, COUNTRY) DATE (MONTH/DAY/YR) DATE (MONTH/DAY/YR) PURPOSE*
......................... From ................ To .................. ...................
......................... From ................ To .................. ...................
......................... From ................ To .................. ...................
......................... From ................ To .................. ...................
......................... From ................ To .................. ...................
......................... From ................ To .................. ...................
......................... From ................ To .................. ...................
......................... From ................ To .................. ...................
(*Indicate purpose of trip: vacation, residence, business, studies, U.S. military
service, U.S. military dependent, etc. If working abroad, give name of employer.
(Continue on separate sheet, if necessary.)
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That my Social Security Number is ........................................;
My Military service number (if applicable) is ........................................;
That I have served in the United States Armed Forces from
..................................... to .....................................
(date) (date)
That I was married on .......................... at ..........................
(date) (place)
to ..............................................................
(name of spouse)
That, to the best my knowledge, I am the natural father/mother of the following
children:
NAME DATE OF BIRTH PLACE OF BIRTH
.............................. ........................ ..............................
.............................. ........................ ..............................
.............................. ........................ ..............................
.............................. ........................ ..............................
.............................. ........................ ..............................
.............................. ........................ ..............................
.............................. ........................ ..............................
.............................. ........................ ..............................
(Continue on separate sheet, if necessary.)
That the other parent of the above-named child/children is
........................................................................................
(name)
whom I first met on ................................... at ..........................
(date) (city, state or country)
That, if any child named above was born out of wedlock and I am the father
through whom such child is claiming United States citizenship, I agree to provide
financial support for such child until such child reaches the age of eighteen
years.*
*NOTE: The preceding phrase may be deleted; however, if it is deleted by a United
States citizen who fathered a child born out of wedlock to a foreign woman, the
child will not be eligible for United States citizenship under Section 309(a) of the
Immigration and Nationality Act, as amended on November 14, 1986.
-3-
WARNING: False statements made knowingly and willfully in passport applications or
affidavits other supporting documents are punishable by fine and/or imprisonment
under the provisions of 18 USC 1001 and /or 18 USC 1542.
I solemnly swear (or affirm) that the statements made on all of the pages of this affidavit
are true and complete to the best of my knowledge and belief and that this affidavit is
for the purpose of establishing my relationship to the aforementioned child/children and
his/her/their claim to United States citizenship.
.......................................................
(Signature of affiant)
..........................................................................................................
(Present Street Address)
..........................................................................................................
(City, State, Country, Zip Code, Telephone Number)
SUBSCRIBED AND SWORN TO (AFFIRMED) before me this ............ day of
..................., 19.... at .....................................................................,
.................................................
(Signature of administering officer)
(SEAL)
CA/OCS 12/97