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<td><img src="media/image1.png"
style="width:0.55625in;height:0.55625in" /></td>
<td colspan="14"><p>U.S. DEPARTMENT OF STATE</p>
<p><strong>APPLICATION FOR CONSULAR REPORT OF BIRTH ABROAD</strong></p>
<h1 id="of-a-citizen-of-the-united-states-of-america">OF A CITIZEN OF
THE UNITED STATES OF AMERICA</h1></td>
<td><p>OMB NO. 1405-0011</p>
<p>Expires 03-31-2001</p>
<p>Estimated Burden: 20 Minutes*</p></td>
</tr>
<tr class="even">
<td colspan="7">A. THIS SECTION TO BE COMPLETED BY APPLICANT</td>
<td colspan="6"><p>Please Type or Print Neatly in Blue or Black Ink</p>
<p>See Instructions on Reverse Side.</p></td>
<td colspan="3">18.</td>
</tr>
<tr class="odd">
<td colspan="13"></td>
<td colspan="3">Serial No.</td>
</tr>
<tr class="even">
<td colspan="5"><p>1. Name of Child in Full <em>(First)
(Middle)</em></p>
<p>     </p></td>
<td colspan="6"><p><em>(Last)</em></p>
<p>     </p></td>
<td colspan="2"><p>2. Sex</p></td>
<td colspan="3">Date Issued <em>(mm/dd/yyyy)</em></td>
</tr>
<tr class="odd">
<td colspan="3"><p>3. Date Of Birth <em>(mm/dd/yyyy)</em></p>
<p>     </p></td>
<td><p>4. Hour</p>
<p>      AM</p>
<p>      PM</p></td>
<td colspan="5"><p>5. Place Of Birth In Full <em>(City, State,
Country)</em></p>
<p>     </p></td>
<td colspan="4"></td>
<td colspan="3"><p>Approved by __________</p>
<p>FS Post</p></td>
</tr>
<tr class="even">
<td colspan="16">THE FOLLOWING ITEMS PERTAIN TO THE NATURAL PARENTS.
COMPLETE FOR BOTH FATHER AND MOTHER.</td>
</tr>
<tr class="odd">
<td colspan="6">FATHER</td>
<td colspan="4">ITEM</td>
<td colspan="6">MOTHER</td>
</tr>
<tr class="even">
<td colspan="6">     </td>
<td colspan="4"><p>6. FULL NAME</p>
<p><em>(Include mother’s maiden name)</em></p></td>
<td colspan="6">     </td>
</tr>
<tr class="odd">
<td colspan="6">     </td>
<td colspan="4"><p>7. DATE OF BIRTH</p>
<p><em>(mm/dd/yyyy)</em></p></td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="6">     </td>
<td colspan="4"><p>8. PLACE OF BIRTH</p>
<p><em>(City, State, Country)</em></p></td>
<td colspan="6">     </td>
</tr>
<tr class="odd">
<td colspan="6">     </td>
<td colspan="4"><p>9. PRESENT ADDRESS</p>
<p><em>(Street No., City, State)</em></p></td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="6">     </td>
<td colspan="4"><p>10. ADDRESS IN THE UNITED STATES</p>
<p><em>(Street No., City, State)</em></p></td>
<td colspan="6">     </td>
</tr>
<tr class="odd">
<td colspan="6">     </td>
<td colspan="4"><p>11. EVIDENCE OF U.S. CITIZENSHIP</p>
<p>IF ALIEN, SHOW NATIONALITY</p></td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="6">     </td>
<td colspan="4"><p>12. PRECISE PERIODS OF PHYSICAL PRESENCE IN UNITED
STATES</p>
<p>(Do not list individual States. Use additional paper, if
necessary)</p></td>
<td colspan="6">     </td>
</tr>
<tr class="odd">
<td colspan="6">     </td>
<td colspan="4">13. PRECISE PERIODS ABROAD IN US ARMED FORCES, IN OTHER
US GOVERNMENT EMPLOYMENT, WITH QUALIFYING INTERNATIONAL ORGANIZATION, OR
AS A DEPENDENT OF SUCH PERSON (Specify)</td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="6">     </td>
<td colspan="4">14. PREVIOUS MARRIAGES. SHOW DATE AND MANNER OF
TERMINATION OF ALL</td>
<td colspan="6">     </td>
</tr>
<tr class="odd">
<td colspan="16"><p>15. Date and Place of Present Marriage
<em>(mm/dd/yyyy, City, State, Country)</em></p>
<p>           </p></td>
</tr>
<tr class="even">
<td colspan="16">B. THIS SECTION TO BE COMPLETED BY CONSULAR OFFICER,
NOTARY PUBLIC OR OTHER PERSON QUALIFIED TO ADMINISTER OATH</td>
</tr>
<tr class="odd">
<td colspan="2">16. AFFIRMATION:</td>
<td colspan="14">I SOLEMNLY SWEAR (OR AFFIRM) THAT THE STATEMENTS MADE
ON THIS APPLICATION ARE TRUE TO THE BEST OF MY KNOWLEDGE AND
BELIEF.</td>
</tr>
<tr class="even">
<td colspan="5"><p>NAME OF PERSON PROVIDING INFORMATION</p>
<p>     </p></td>
<td colspan="5">SIGNATURE</td>
<td colspan="6"><p>RELATIONSHIP TO CHILD</p></td>
</tr>
<tr class="odd">
<td colspan="2"><p>SUBSCRIBED TO:</p>
<p><em>(SEAL)</em></p></td>
<td colspan="6">TYPED NAME AND TITLE OF OFFICIAL</td>
<td colspan="4">SIGNATURE OF OFFICIAL</td>
<td colspan="2">CITY</td>
<td colspan="2">DATE (mm//dd/yyyy)</td>
</tr>
<tr class="even">
<td colspan="16">C. THIS SECTION TO BE COMPLETED BY CONSULAR OFFICE</td>
</tr>
<tr class="odd">
<td colspan="16"><p>17. DOCUMENTS PRESENTED:</p>
<p>18. (See upper right corner) Other:</p></td>
</tr>
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</table>

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| DS-  | \*The response time is an estimated average including the     |
| 2029 | time needed to look for, get, and provide the information     |
|      | required. You do not have to provide the information          |
| /SS5 | requested if the OMB approved date has expired. We would      |
|      | appreciate any comments on the estimated response burdens,    |
| 02-  | and recommendations for reducing them. Please send your       |
| 2000 | comments to A/RPS/DIR, U.S. Department of State, Washington,  |
|      | DC 20520.                                                     |
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