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AFFIDAVIT OF PARENTAGE AND PHYSICAL PRESENCE I_ _print your full

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					                            AFFIDAVIT OF PARENTAGE AND PHYSICAL PRESENCE

I, (print your full name) ____________________________________________, do solemnly
swear (or affirm) that: (Continue on separate sheets by item #, if necessary. If not applicable
please print “N/A” or “NONE”. Please print legibly in block letters or your affidavit will be
disregarded.)

1. I am an American citizen by (choose one):
                                 Date                                              City and State or Country
       Birth in the U.S.

          Naturalization

          Birth abroad to
          U.S. parents

2. I have been physically present in the U.S. as follows:
          City, State                 Month/Day/Year from                                      Month/Day/Year to




3. I have been physically present outside the U.S. as follows:
        City, Country          Month/Day/Year from Month/Day/Year to                                 Purpose




4. My Social Security # is: ________________________.

5. I have served on active duty in the U.S. Armed Forces as follows:
       Branch of service              Month/Day/Year from                                      Month/Day/Year to



6. I am married:
     Name of spouse                        Date of marriage                   Place of marriage          U.S. citizen?


7. I was previously married:
  Name of my former spouse                                     Date of marriage             Date of divorce or death


8. My spouse was previously married:
  Name of spouse’s former spouse                                    Date of marriage        Date of divorce or death




w/cons/acs/acsforms/ C-3_Affidavit of Parentage and Physical Presence
               AFFIDAVIT OF PARENTAGE AND PHYSICAL PRESENCE - CONTINUED

9. To the best of my knowledge, I am the birth father/mother of the following children:
          Name              U.S. citizen?      Date of birth               Place of birth




10. If any of the above named children were born out of wedlock the other parent is:
           Name             U.S. citizen?   Meeting date     Place of meeting Child’s name



If any child named above was born out of wedlock and if I am the father through whom such
child is claiming U.S. citizenship, I agree to provide financial support for such child until such
child reaches the age of 18 years. NOTE: You may delete the preceding statement; however, if
it is deleted by a U.S. citizen who fathered a child born out of wedlock to a foreign mother, the
child is INELIGIBLE for U.S. citizenship per INA 309(a).

11. I have the following adopted children:
          Name                Date of birth                             Place of birth       U.S. citizen?



WARNING: False statements made knowingly and willfully in passport applications or affidavits
or 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 U.S.
citizenship.

Signature

Address

Telephone and Email


SUBSCRIBED AND SWORN TO before me on (date) _________________________ at the
U.S. Consulate General, Toronto, Canada.

                                                                           ______________________________
                                                                                                 (Vice) Consul
                                             (SEAL)

w/cons/acs/acsforms/ C-3_Affidavit of Parentage and Physical Presence

				
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