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EASY FORM FILLER - US PASSPORT

Lost or Stolen Passport - DS-64 Form

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Lost or Stolen Passport - DS-64 Form
U.S. Department of State OMB Control No. 1405-0014 Expiration Date:  Estimated Burden: 5 Minutes Page 1 of 2 DS-64  +2: 72 5(3257 $ 9$/,' /267 25 672/(1 3$663257 %22. $1'25 &$5' To report a valid lost or stolen passport ERRN DQGRU FDUG please choose ONE of the following options: 1. ONLINE: Visit our website at travel.state.gov. OR OR 3. BY PHONE: Call 1-877-487-2778 (TDD: 1-888-874-7793) and follow the representative's instructions. This option is not available for customers abroad. OR 4. BY MAIL: Submit this form AND a front and back photocopy of a government-issued photo identification (such as a driver's license or state-issued identification) to the following address ONLY IF you are NOT applying for a new U.S. passport book and/or card: ATTN: CLASP U.S. Department of State CA/PPT/S/50&/$63 44132 Mercure Cir P.O. Box 1227 Sterling, VA 20166-1227 * Only use this address to submit this form or other correspondence about lost/stolen passports. For general inquiries, call the National Passport Information Center at 1-877-487-2778. Protect yourself against identity theft! Report a lost or stolen U.S. passport! For more information, please visit our website: travel.state.gov :$51,1* False statements made knowingly and willfully on this form, in U.S. passport applications, or in affidavits or other supporting documents submitted therewith are punishable by fine and/or imprisonment under U.S. law, including the provisions of 18 U.S.C. 1001 and/or 18 U.S.C. 1542. Alteration or mutilation of a U.S. passport is punishable by fine and/or imprisonment under the provisions of 18 U.S.C. 1543. The use of a U.S. passport in violation of the restrictions contained therein or of the passport regulations is punishable by fine and/or imprisonment under 18 U.S.C. 1544. All statements and documents submitted are subject to verification. 35,9$&< $&7 67$7(0(17 AUTHORITIES: We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 8 U.S.C. 1737; Executive Order 11295 (August 5, 1966); and 22 C.F.R. Parts 50 and 51. PURPOSE: 7he information UHTXHVWHG RQ WKLV IRUP LV XVHG to ensure that no one has more than one valid U.S. passport book DQG RQH YDOLG 86 passport card at any one time, except as authorized by the U.S. Department of State, and to combat passport IUDXG DQG PLVXVH 7he collection of the Social Security number will be used to verify the identity of the person reporting the lost RU VWROHQ SDVVSRUW DQG to identify the passport being reported lost or stolen. There is no other purpose unless authorized by law. DISCLOSURE: Providing your Social Security number and other information on this form is voluntary, but failure to provide the information on this form may, given the form's purpose of verification of your identity, result in processing delays. 3$3(5:25. 5('8&7,21 $&7 67$7(0(17 Public reporting burden for this collection of information is estimated to average five minutes per response, including time required for searching existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: 3DVVSRUW )RUPV 2IILFHU U.S. Department of State, Bureau of Consular Affairs, Passport Services, Office of Program Management DQG 2SHUDWLRQDO Support, 44132 Mercure Cir., P.O. Box 1199, Sterling, VA 20166-1199. 5287,1( 86(6 7KLV LQIRUPDWLRQ PD\ EH GLVFORVHG WR DQRWKHU GRPHVWLF JRYHUQPHQW DJHQF\ D SULYDWH FRQWUDFWRU D IRUHLJQ JRYHUQPHQW DJHQF\ RU WR D SULYDWH SHUVRQ RU SULYDWH HPSOR\HU LQ DFFRUGDQFH ZLWK FHUWDLQ DSSURYHG URXWLQH XVHV 7KHVH URXWLQH XVHV LQFOXGH EXW DUH QRW OLPLWHG WR ODZ HQIRUFHPHQW DFWLYLWLHV HPSOR\PHQW YHULILFDWLRQ IUDXG SUHYHQWLRQ ERUGHU VHFXULW\ FRXQWHUWHUURULVP OLWLJDWLRQ DFWLYLWLHV DQG DFWLYLWLHV WKDW PHHW WKH 6HFUHWDU\ RI 6WDWHV UHVSRQVLELOLW\ WR SURWHFW 86 FLWL]HQV DQG QRQFLWL]HQ QDWLRQDOV DEURDG )RU D PRUH GHWDLOHG OLVWLQJ RI WKH URXWLQH XVHV WR ZKLFK WKLV LQIRUPDWLRQ PD\ EH SXW SOHDVH VHH WKH 'HSDUWPHQW RI 6WDWHV 3UHIDWRU\ 6WDWHPHQW RI 5RXWLQH 8VHV 3XEOLF 1RWLFH  RI -XO\   DQG WKH OLVWLQJ RI URXWLQH XVHV VHW IRUWK LQ WKH 6\VWHP RI 5HFRUGV 1RWLFHV IRU 2YHUVHDV &LWL]HQ 6HUYLFHV 5HFRUGV DQG 2WKHU 2YHUVHDV 5HFRUGV 6WDWH DQG 3DVVSRUW 5HFRUGV 6WDWH STATEMENT REGARDING A VALID LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD ,I \RXU PRVW UHFHQW ORVW RU VWROHQ SDVVSRUW LV H[SLUHG LW LV QR ORQJHU YDOLG DQG \RX GR QRW QHHG WR VXEPLW WKLV IRUP 2. WHILE APPLYING FOR A NEW U.S. PASSPORT: Submit this form with a new DS-11, Application for D U.S. Passport along ZLWK required documentation to any designated acceptance facility, U.S. passport agency, U.S. embassy, or U.S. consulate abroad.
U.S. Department of State STATEMENT REGARDING A VALID LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD OMB Control No. 1405-0014 Expiration Date:  Estimated Burden: 5 Minutes Page 2 of 2 DS-64  IMPORTANT NOTICE A U.S. national may not normally bear more than one valid or potentially valid U.S. passport book and/or card at a time. Therefore, a statement is required when applying for a new U.S. passport if the previously valid or potentially valid passport is not submitted. Your statement must detail Zhy the previous valid U.S. passport cannot be presented. The information you provide on this form will be placed into the Consular Lost and Stolen Passport System, which is designed to prevent the misuse of all reported valid lost or stolen U.S. passports. If more than one valid U.S. passport previously issued to you was lost or stolen, your replacement passport may be limited in validity. ONCE REPORTED, THE VALID LOST OR STOLEN PASSPORT IS ELECTRONICALLY CANCELLED AND CANNOT BE USED FOR TRAVEL. Anyone (including the bearer) traveling on a reported lost or stolen passport may be detained upon entering the United States. Should you locate the passport after reporting it lost or stolen, submit it for cancellation to the Consular Lost and Stolen Passport Unit (CLASP). See page one of this form for contact information. Please select the document (or documents) that you are reporting and its status. Valid U.S. Passport Book Lost Stolen Valid U.S. Passport Card Lost Stolen Are you submitting this form in connection with an application for a new U.S. passport book and/or card? Yes No Last Name First Name Middle Name Has your name changed since the passport was issued? If yes, state the name in which the YDOLG lost or stolen passport was issued. Date of Birth (mm-dd-yyyy) Place of Birth (City & State if in U.S. or City & Country) Social Security Number Current Address (Street, City, State, and ZIP Code or Country, if outside the U.S.) Telephone Number Alternative Telephone Number Email Address $QVZHU DOO TXHVWLRQV FRPSOHWHO\ ,I \RX GR QRW NQRZ WKH DQVZHU LQ GHWDLO EH DV H[DFW DV SRVVLEOH 7KH SDVVSRUW ERRN DQG FDUG KDYH GLIIHUHQW QXPEHUV 3OHDVH SURYLGH WKH FRUUHFW QXPEHUV LI NQRZQ 7KH SDVVSRUW QXPEHU RQ D ORVW RU VWROHQ SDVVSRUW FDQQRW EH UHXVHG Explain in detail how your valid U.S. passport book/card was lost or stolen. Include a photocopy of the valid passport book/card if available. Explain where the loss or theft occurred. Provide the address, if known (City and State, if in the U.S., or City and Country as it is presently known) On what date was your valid U.S. passport book/card lost or stolen (mm-dd-yyyy)? If unknown, when was the last time you remember it being in your possession? Did you file a police report? (If yes and the report is available, please submit a copy.) Yes No List your valid lost or stolen U.S. Passport Book, if known: List your valid lost or stolen U.S. Passport Card, if known: Number Issue Date (mm-dd-yyyy) Number Issue Date (mm-dd-yyyy) Have you had any other valid U.S. passport book/card lost or stolen? Yes No If yes, how many passports? Approximate date(s)? (mm-dd-yyyy)  <28 0867 6,*1 $1' '$7( 7+( $33/,&$7,21 ,1 7+( '(6,*1$7(' $5($ %(/2: I, the undersigned, declare under penalty of perjury all of the following: 1) that I have read and understDQG the warning on page one of this form; 2) the information provided herein is correct and complete; 3) I have not given my U.S. passport book and/or passport card to another person or disposed of it in an unauthorized manner; 4) I understand that the U.S. passport(s) I report as missing will be invalidated and cannot be used; and 5) if I subsequently find and recover it, I will immediately return the passport ERRN and/or passport card to Passport Services at the address on page one of WKLV form or to the nearest U.S. passport agency, U.S. embassy or U.S. consulate if abroad, and I will not attempt to use it. Applicant's Legal Signature - age 16 or older Date (mm/dd/yyyy) Mother/Father/Parent/Guardian Legal Signature if identifying minor under age 16 Date (mm/dd/yyyy) Mother/Father/Parent/Guardian Legal Signature if identifying minor under age 16 Date (mm/dd/yyyy) Both parents or guardians of a child younger than 16 years old must sign and provide a front and back photocopy of ID when submitting this form on the child's behalf unless one parent or guardian has sole authority to obtain a passport pursuant to 22 C.F.R. 51.28. If there is sole authority, include a copy of a supporting document with this form, such as a court order proving sole legal custody or form DS-5525, Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor Under Age 16. Please Print Legibly RU 7\SH Using Black Ink Only. Did you file a police report? (If yes and the report is available, please submit a copy.) Yes No 7\SH RU SULQW OHJLEO\ LQ EODFN LQN LQ ZKLWH DUHDV RQO\  ,'(17,)<,1* ,1)250$7,21 2) 3$663257 +2/'(5  9$/,' /267 25 672/(1 86 3$663257 %22.&$5' ,1)250$7,21