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Statement Of Non-Receipt Of A Passport DS-86 - Official Federal Forms

Statement Of Non-Receipt Of A 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 Approval No.: 1405-0146 Expiration Date: 07-31-2014 Estimated Burden: 5 Minutes STATEMENT OF NON-RECEIPT OF A PASSPORT IMPORTANT NOTICE A U.S. citizen may not normally bear more than one valid or potentially valid U.S. passport book and one valid U.S. passport card at a time. You have 90 days from the date that your passport document(s) was issued to report that you have not yet received it in the mail. If you do not report the non-receipt of your U.S. passport document(s) within 90 days of the issue date, you will be required to reapply and submit the full passport fee. To check the status of your U.S. passport application please visit travel.state.gov or contact our National Passport Information Center (NPIC) 1-877-487-2778 (TDD: 1-888-874-7793). The information that you provide on the DS-86, Statement of Non-Receipt of a Passport, will be placed into the Consular Lost or Stolen Passport System. Anyone using the U.S. passport book or U.S. passport card reported on the DS-86, including yourself, may be detained. Should you receive the document you reported as non-received at a later time, report it as found and submit it for cancellation. It has been invalidated. You may not use it for travel. See page two of this form for additional information. This application must be accompanied with a clear photocopy of an identification containing your photo. Protect yourself against identity theft! Report the non-receipt of your passport book or passport card! Type or print legibly in black ink in the white areas only. Please select the document(s) which you are reporting. U.S. Passport Book Last Name First Name U.S.Passport Card Middle Name Date of Birth (mm-dd-yyyy) Primary Telephone Number Secondary Telephone Number Mailing Address: Street Address Apartment /Unit City State ZIP Code I, the undersigned, certify that I have not received the U.S. passport book and/or U.S. passport card for which I applied for. I declare under penalty of perjury that the statements made on this form are true and correct. I request that a new U.S. passport book and/or U.S. passport card be issued to me and certify that if I receive the U.S. passport book and/or U.S. passport card previously applied for, I will immediately contact the National Passport Information Center at 1-877-487-2778 (TDD: 1-888-874-7793) and return the recovered passport to the U.S. Department of State. Applicant's Signature - age 16 and older Parent's/Legal Guardian's Signature Date (mm-dd-yyyy) PASSPORT OFFICE USE ONLY Was the passport mailed to the correct mailing address? Tracking Number: Previous U.S. Passport Book Number Place Issued Previous U.S. Passport Card Number Place Issued DS-86 08-2012 Date Mailed (mm-dd-yyyy) Date Mailed (mm-dd-yyyy) Yes No Vendor: Was delivery confirmed? USPS UPS Yes Fed Ex No DHL Date Issued (mm-dd-yyyy) Special Postage, If Used Date Issued (mm-dd-yyyy) Special Postage, If Used Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com HOW TO USE THIS FORM This form must be mailed to the passport agency that originally processed your application. To obtain the address of that agency please call the National Passport Information Center at 1-877-487-2778 (TDD: 1-888-874-7793). For more information, please visit our website at travel.state.gov. WARNING False statements made knowingly and willfully in passport applications or in affidavits or other supporting documents submitted therewith are punishable by fine and/or imprisonment under the provisions of 18 U.S.C 1001, 18 U.S.C. 1542, and/or 18 U.S.C. 1621. Alteration or mutilation of a U.S. passport issued pursuant to this application 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 are subject to verification. PRIVACY ACT STATEMENT 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; 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 establish the need for a replacement U.S. passport to customers who have not received the passport for which they originally applied. 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 U.S. 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, or otherwise address potential violations of law or to further the Secretary's responsibility for the protection of U.S. citizens and non-citizen nationals abroad. For a more detailed listing of the routine uses to which this information may be put see the Department of State's Prefatory Statement of Routine Uses relative to the Privacy Act (Public Notice 6290 of July 15, 2008) and the listing of routine users set forth in the System of Records Notices for Overseas Citizen Services Records (State-05) and Passport Records (State-26) published in the Federal Register. Providing the information requested on this form is voluntary. Failure to provide the information requested may result in processing delays or the denial of your U.S. passport application. PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time required for searching existing data sources, gathering the necessary data, providing the information and/or documentation required, and reviewing the final collection. You do not have to supply this information unless the 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 A/GIS/
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