DS-5507 Affidavit of Physical Presence or Residence ...

1 U. S. Department of StateDS-550701-2016 Affidavit OF Physical Presence OR Residence , parentage AND SUPPORTOMB NO. 1405-0187 EXPIRES - 01-30-2019 Estimated Burden - 30 minutesPage 1 of 5I, do solemnly swear (or affirm): That I am a non-citizen national by: 1) birth inon2) naturalization onbefore theCity/Town, State in the United StatesDate Date Name of Court and State3) birth abroad onDate (mm-dd-yyyy)to citizen(s) or non-citizen national(s) in(mm-dd-yyyy)(mm-dd-yyyy)(Continued on the next page)CONSULAR AND PASSPORT OFFICES OF THE UNITED STATES OF AMERICAPART I That I am (mm-dd-yyyy)toName of ChildDate of Birth Place of Birth(Continue on a separate sheet, if necessary)NameName(All applicants please complete Part I)(choose one)CountryMarried (choose all that apply)

2 Married onDate That I am the biological parent of:CountryinPreviously Married (mm-dd-yyyy)SingleIf terminated, list date and manner of termination ( death or divorce)(Please use a separate sheet to list additional marriages and marriage termination information.)or enter N/A. DS-5507 Page 2 of 5(Continued on the next page)That I have been physically present or have had a Residence in the United States as follows:Place (Continue on a separate sheet, if necessary)(City, State)Date(mm-dd-yyyy)Date(mm-dd-yyyy)Fr omToPlacePurpose:That I have been physically present or resident abroad as follows:(Country)(Continue on a separate sheet, if necessary)(Indicate purpose of stay: vacation, Residence , business, studies, government employment, government/military service or dependent, etc.)

3 If working abroad give name of employer)FromTo(mm-dd-yyyy)Date Date(mm-dd-yyyy)That the other biological parent of the above-named child/children for whom this application for a Consular Report of Birth and/or is being filed is:is a citizen or national of the not a citizen of the the other parent is a non-citizen national it is by:1) birth inon2) naturalization onbefore theCity/Town, State in the United StatesDate Date Name of Court and State3) birth abroad onDate to citizen(s) non-citizen national(s) in(mm-dd-yyyy)(mm-dd-yyyy)(mm-dd-yyyy)Co untryFromToFromToFromToFromToFromToFromT oFromToNamePurpose (Indicate purpose of stay: vacation, Residence , business, studies, etc.

4 FromToFromToFromToFromToFromToFromToPlac e (City, State)Date (mm-dd-yyyy)Date(mm-dd-yyyy)The other biological parent has been physically present or has had a Residence in the United States as follows: (INFORMATION ABOUT THE UNMARRIED NON-APPLYING PARENT SHOULD ONLY BE PROVIDED IF THAT PARENT IS A CITIZEN OR NON-CITIZEN NATIONAL)(Continue on a separate sheet, if necessary) Part II of this document must be signed before a Consular Officer, Passport Specialist, or designated Consular/Acceptance Agent at the time the oath is sworn.

5 Subscribed and sworn before me thisday of, . [SEAL]Signature and Title of Consular Officer, PassportSpecialist or designated Consular/AcceptanceAgent Administering OathMy child was born out of wedlock, and I am the biological father through whom such child is claiming citizenship. I agree to provide financial support for such child until he/she reaches the age of eighteen of AffiantPLEASE STOP HERE!(All applicants with a child/children born out of wedlock)PART IIDS-5507 Page 3 of 5(Continued on the next page)Purpose (Indicate purpose of stay: vacation, Residence , business, studies, etc.)

6 Part III of the document must be signed before a Consular Officer, Passport Specialist, or designatedConsular/Acceptance Agent at the time the oath is AND SWORN TO (AFFIRMED) before me this day of,at,Signature and Title of Administering Officer,[SEAL] DS-5507 Page 4 of 5 WARNING: False statements made knowingly and willfully in applications for citizenship documentation or affidavits and other supportingdocuments are punishable by fine and/or imprisonment under the provisions of 18 USC 1001 and other applicable criminal Consular Officer or Passport Specialist may require additional evidence of one's blood relationship to one's child and/or evidence ofone's Physical Presence or Residence in the United solemnly swear (or affirm)

7 That all the statements contained in 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 of affiantPART III(Oath: To be completed by all applicants)Present Street AddressStateCountryCityZip CodeTelephone NumberPLEASE STOP ACT STATEMENTAUTHORITY: The State Department is authorized to collect this information pursuant to8 1104(a)(1), 1104(a)(3), 1401, 1408, 1409, 22 211(a) and : The principal purpose of the information gathered is to determine if a parent(s) has met the statutory Physical Presence or residencerequirements to transmit citizenship to his/her child born abroad or in the UnitedStates for non-citizen nationality; to establish parentage of the child.

8 And to fulfillthe requirements of 8 1409(a), which permits acknowledgment of paternity underoath and requires the citizen father s written agreement to provide financial supportfor his children born abroad out of USES: The information solicited on this form may be made available toFederal government entities such as the Social Security Administration, the Departmentof Homeland Security, and Department of Justice, in connection with determinations ofcitizenship status, administration of federal benefits, and law enforcement purposes asset forth in the System of Records Notice for Overseas Citizens Records, STATE-05, 73FR 24342 (2008) and the Department wide Prefatory Statement of Routine Uses, 73 FR40649-40651 (2008).

9 Information also can be made available to appropriate federal, state,local or foreign government entities, such as state law enforcement agencies, stateprosecutors, judicial staff, local police, and INTERPOL, in connection with lawenforcement, safety, welfare and related matters, as set forth by the System of RecordsNotice for Overseas Citizens Records, STATE-05, 73 FR 24342 (2008). These mattersinclude custody disputes and notification of next of the information on this form is voluntary; however, failure to furnish therequested information may delay or prevent you from documenting your child as a or national.

10 PAPERWORK REDUCTION ACT (PRA) STATEMENTP ublic reporting burden for this collection of information is estimated to average 30minutes per response, including time required for searching existing data sources,gathering the necessary documentation, providing the information and/or documentsrequired, and reviewing the final collection. You do not have to supply this informationunless this collection displays a currently valid OMB control number. If you havecomments on the accuracy of this burden estimate and/or recommendations forreducing it, please send them to: CA/OCS/PMO, 10th Floor, SA-17, Department ofState, Washington, DC 20036.