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Statement Regarding Lost Or Stolen Passport DS-64 - Official Federal Forms
| Statement Regarding Lost Or Stolen Passport Form. This is a national form and can be used in Passport US Department Of State . |
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U.S. Department of State OMB No. 1405-0014 Expires: 05-31-2013 Estimated Burden: 5 Minutes* STATEMENT REGARDING A LOST OR STOLEN PASSPORT BOOK AND/OR CARD IMPORTANT NOTICE A U.S. citizen may not normally bear more than one valid or potentially valid U.S. passport book and one valid passport card at a time. It therefore is necessary to submit a statement with an application for a new U.S. passport when a previously issued valid or potentially valid U.S. passport book/card cannot be presented. Your statement must detail why the previous U.S. passport book/card cannot be presented. The information you provide on the DS-64, Statement Regarding a Lost or Stolen Passport Book and/or Card, will be placed into our Consular Lost and Stolen Passport System. This system is designed to prevent the misuse of your lost or stolen U.S. passport book/card. Anyone using a passport book/card reported on the DS-64, including yourself, may be detained upon entry into the United States. Should you locate the passport reported lost or stolen at a later time, you should report it as found and submit it for cancellation. It has been invalidated. You may not use that passport for travel. See page 2 of this form for additional information. Protect yourself against identity theft! Report a lost or stolen passport book or passport card! Please select the document (or documents) which you are reporting and its status. U.S. Passport Book Lost Stolen U.S. Passport Card Lost Stolen 1. IDENTIFYING INFORMATION: Type or print legibly in black ink in white areas only. Last Name First Name Middle Name Has your name changed since the passport was issued? If yes, state the name in which the lost or stolen passport was issued. Sex Female Male 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) Home Telephone Number Work Telephone Number E-mail Address ( ) ( ) Answer all questions completely. If you do not know the 2. LOST OR STOLEN PASSPORT BOOK/CARD INFORMATION: answer in detail, be as exact as possible. List your lost or stolen passport numbers: Passport Book Passport Card List the date(s) your lost or stolen passport(s) were issued: (mm-dd-yyyy) Passport Passport Book Card How, where and on what date did the loss or theft take place? What efforts were made to recover the passport? If you have had any other U.S. passport book and/or card lost or stolen, give the approximate date of this loss or theft and any additional information you can provide. If the space provided is not sufficient to answer the question, please continue answering the question on a separate piece of paper. Are you submitting this form in connection with an application for a new passport book and/or card? Yes No I, the undersigned, declare under penalty of perjury all of the following: 1) That I have read and understood the warning on page two of this form 2) The information furnished herein is correct and complete and that I have not given my passport book and/or passport card to another person or disposed of it in an unauthorized manner. I understand that the passport(s) I report as missing will be invalidated and cannot be used. If I subsequently find and recover it, I will immediately return it to Passport Services at the address on the back of this form or to the nearest U.S. passport agency, U.S. embassy, or U.S. consulate abroad. Legal Signature - age 16 or older DS-64 05-2011 Date (mm/dd/yyyy) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com HOW TO REPORT YOUR LOST OR STOLEN PASSPORT BOOK AND/OR PASSPORT CARD If you are applying for a new passport book and/or card, please submit this form with a new DS-11 passport application to any designated acceptance facility, U.S. passport agency, U.S. embassy, or U.S. consulate abroad. OR If you are not currently applying for a new passport book and/or card, send this form or a recovered lost or stolen passport to the following address: U.S. Department of State Passport Services Consular Lost/Stolen Passport Section Attn: CLASP 1111 19th Street, NW, Suite 500 Washington, DC 20036 (Please do not attempt to use this address for any passport related service other than that described above.) To report your lost or stolen passport by phone, call: 202-955-0430 For more information, please visit our website at travel.state.gov WARNING False statements made knowingly and willfully on this form, in 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. PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS AUTHORITIES: Collection of the information solicited on this form is authorized by Titles 8 and 22 of the United States Code, and other applicable laws and regulations, including 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; Section 236 of the Admiral James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001; Executive Order 11295 (August 5, 1966); and 22 C.F.R. parts 50 and 51. PURPOSE: The primary purpose for soliciting the information is to ensure that no person shall bear more than one valid or potentially valid U.S. passport book and one valid passport card at any one time, except as authorized by the U.S. Department of State, and to combat passport fraud and misuse. ROUTINE USES: The information solicited on this form may be made available as a routine use to other government agencies and private contractors to assist the U.S. Department of State in adjudicating passport applications and requests for related services, and for law enforcement, fraud prevention, border security, counterterrorism, litigation activities, and administrative purposes. The information may be made available to foreign government agencies to fulfill passport control and immigration duties. The information may also be provided to foreign government agencies, international organizations and, in limited cases, private persons and organizations to investigate, prosecute
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