Application For A U.s. Passport (Form Ds-5504)

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APPLICATION FOR A U.S. PASSPORT
OMB APPROVAL NO. 1405-0160
NAME CHANGE, DATA CORRECTION, AND LIMITED PASSPORT BOOK REPLACEMENT
EXPIRATION DATE: 12-31-2013
Please Print Legibly Using Black Ink Only
ESTIMATED BURDEN: 30 MIN
Attention: Read WARNING on page 1 of instructions
Please select the document(s) for which you are applying:
U.S. Passport Book
U.S. Passport Card
Both
The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions.
28 Page Book (Standard)
52 Page Book (Non-Standard)
Note: The 52 page option is for those who frequently travel abroad during the passport validity period and is recommended
for applicants who have previously required the addition of visa pages.
1. Name Last
D
O
DP
DOTS Code
End. #
Exp.
First
Middle
2. Date of Birth (mm/dd/yyyy)
3. Sex
4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.)
M
F
-
-
6. Email Address (e.g. )
5. Social Security Number
7. Primary Contact Phone Number
-
-
-
-
@
8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.
Address Line 2: Clearly label Apartment, Company, Suite, Unit, Building, Floor, In Care Of or Attention if applicable. (e.g. In Care Of - Jane Doe, Apt # 100)
City
State
Zip Code
Country, if outside the United States
9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed.)
A.
B.
10. Passport Book and/or Passport Card Information
Your name as listed on your most recent passport book and/or passport card
Most recent passport book number
Book Issue Date (mm/dd/yyyy)
Card Issue Date (mm/dd/yyyy)
Most recent passport card number
Submit a recent,
color photographs
CONTINUE TO PAGE 2
YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW
I declare under penalty of perjury all of the following: 1) I am a citizen or non-citizen national of the United States and have not, since acquiring U.S. citizenship or nationality,
performed any of the acts listed under "Acts or Conditions" on the reverse side of this application (unless explanatory statement is attached); 2) the statements made on the
application are true and correct; 3) I have not knowingly and willfully made false statements or included false documents in support of this application; 4) the photograph submitted
with this application is a genuine, current photograph of me; and 5) I have read and understood the warning on page one of the instructions to the application form.
x
Applicant's Signature - age 16 and older
Date
FOR ISSUING OFFICE ONLY
x
Parent's/Legal Guardian's Signature
Name Change
Replacement
Correction:
LName
FName
MName
DOB
Sex
POB
Other
From:
To:
BC
Nat/Citz Cert
Report of Birth
Prev PPT
MC
Adoption C/O
NC C/O
PIERS
Other
Filed/Issued/Place:
Doc #:
Other:
Attached:
EF
Postage
Other
* DS 5504 A 12 2010 1 *
DS-5504 12-2010
Page 1 of 2

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