Ds 5520 Supplemental Questionnaire To Determine Identity For Us Passport Page 2
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3U.S. Department of State
OMB Approval No.: 1405-xxxx
SUPPLEMENTAL QUESTIONNAIRE TO DETERMINE
Expiration Date: xx-xx-xxxx
Estimated Burden: 45 minutes
IDENTITY FOR A U.S. PASSPORT
Section A: Biographical Information
1. Full Name:
(First, Middle, Last)
2. Date of Birth:
3. Social Security Number:
-
-
(month)
(day)
(year)
4. Place of Birth (City, State/Country):
Section B: Information About Your Family (Living and Deceased)
Place of Birth
Full Name
Relationship
Date of Birth
Current Address
(City, State, Country)
Example
Example
Example
Example
Example
Anytown,
123 Elm St. Anytown,
Brother
Joe Smith
12-25-1980
Anystate, USA
Anystate
Father/Parent
Stepfather/Parent
Mother/Parent
Stepmother/Parent
Sibling
Sibling
Sibling
Sibling
Section C: Employment
Please list your last three places of employment (if applicable)
If self-employed or a contractor working remotely, provide your home addresses.
If active duty military, provide 3 most recent duty stations.
Company Name
Address
City, State
Country
Time Employed
Example
Example
Example
Example
Example
ABC
1001 West Elm Drive
Anytown, Anystate
USA
2004-2008
Industries
DS-5520 06-2013
Page 2 of 3
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