Statement Of Non-Receipt Of A Passport {DS-86}

U.S. Department of State STATEMENT OF NON-RECEIPT OF A U.S. PASSPORT IMPORTANT NOTICE OMB Approval No. 1405-0146 Expiration Date: 09-30-2017 Estimated Burden: 15 Minutes 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(s). 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 U.S. Passport, will be entered 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 not 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 by a clear photocopy of the front and back of an identification document containing your photograph. Protect yourself against identity theft! Report the non-receipt of your U.S. passport book or U.S. 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 Social Security Number First Name Date of Birth (mm-dd-yyyy) Primary Telephone Number U.S. Passport Card Middle Name Secondary Telephone Number Travel Date (mm-dd-yyyy) 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. 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 for which I previously applied, 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) Mother/Father/Parent/Legal Guardian's Signature (if applicant is under age 16) Date (mm-dd-yyyy) PASSPORT OFFICE USE ONLY Was the passport mailed to the correct mailing address? Tracking Number: Yes No Was delivery confirmed? Vendor: USPS UPS Yes Fed Ex No DHL Previous U.S. Passport Book Number Place Issued Previous U.S. Passport Card Number Place Issued DS-86 03-2014 Date Mailed (mm-dd-yyyy) Date Mailed (mm-dd-yyyy) 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 To determine how and when to use this form, please call the National Passport Information Center (NPIC) at 1-877-487-2778 (TDD: 1-888-874-7793). This form must be mailed to the passport agency that originally processed your application. To obtain the address of that agency, please call NPIC at the number above. 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: The information on this form is requested under the authority of 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E; Executive Order 11295 (August 5, 1966); and 22 C.F.R. parts 50 and 51. PURPOSE: The information collected on this form will be used to determine whether to issue you a replacement U.S. passport. The collection of the Social Security number will be used for identity/entitlement to passport verification only and no other purpose unless authorized by law. ROUTINE USES: This information may be disclosed to another domestic government agency, a private contractor, a foreign government agency, or to a private person or private employer in accordance with certain approved routine uses. These routine uses include, but are not limited to, law enforcement activities, employment verification, fraud prevention, border security, counterterrorism, litigation activities, and activities that meet the Secretary of State's responsibility to protect U.S. citizens and non-citizen nationals abroad. More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas Citizen Services Records and State-26, Passport Records. DISCLOSURE: Providing your Social Security number and the 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 or entitlement, result in processing delays or denial of your passport application. PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is estimated to average 15 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 U.S. Department of State, Bureau of Consular Affairs, Passport Services, Office of Program Management and Operational Support, 2201 C Street, NW, Washington, DC 20520. DS-86 Page 2 of 2 American LegalNet,