Report Form Loss/theft Of Passport Containing U.s. Visa

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REPORT FORM
LOSS/THEFT OF PASSPORT CONTAINING U.S. VISA
TODAY’S DATE: ____________/__________/_______
(Month)
(Date)
(Year)
PERSONAL INFORMATION
FULL NAME (as shown in passport) _________________________________________________________________
OTHER NAMES USED (maiden, pet name, etc): _______________________________________________________
DATE OF BIRTH: ________/________/_______ PLACE OF BIRTH: ______________________________________
(Month)
(Day)
(Year)
MAILING ADDRESS: ____________________________________________________________________________
TELEPHONE NUMBER: _________________________________________________________________________
SPOUSE’S NAME (including maiden name): __________________________________________________________
FATHER’S FULL NAME: _________________________________________________________________________
MOTHER’S FULL NAME (including maiden name):____________________________________________________
LOST PASSPORT INFORMATION
LOST PASSPORT NUMBER: _________________________ ISSUING COUNTRY: _________________________
ISSUANCE DATE: _________/____________/__________ EXPIRATION DATE: ________/_________/_________
(Month)
(Day)
(Year)
(Month)
(Day)
(Year)
U.S. VISA INFORMATION
DATE OF VISA ISSUANCE: ________/_______/_________ EXPIRATION DATE: ________/________/_________
(Month)
(Day)
(Year)
(Month)
(Day)
(Year)
CITY WHERE VISA ISSUED: _______________________ LAST VISIT TO THE U.S.________/_______/______
(Month)
(Day)
(Year)
VISA CATEGORY (circle one of the following): B-1; B-2; C; D; F; OTHER _________________________________
NUMBER OF ENTRIES PERMITTED (circle one): ONE; TWO; MULTIPLE; OTHER _______________________
PERIOD OF VALIDITY (circle one): ONE YEAR; TWO; FIVE; TEN; OTHER_______________________________
FOR OFFICE USE:
Control # _________________________
Foil # _________________________
LOSS/THEFT INFORMATION
DATE PASSPORT WAS LOST/STOLEN: ________________/__________________/_________________________
(Month)
(Day)
(Year)
PLACE PASSPORT WAS LOST/STOLEN: ___________________________________________________________
POLICE STATION AT WHICH INCIDENT WAS REPORTED: __________________________________________
DATE WHEN REPORTED TO POLICE: ________________/___________________/_________________________
(Month)
(Day)
(Year)
________________________________
SIGNATURE
FOR OFFICE USE, MUST
NOTE: ALL SECTIONS, EXCEPT THE LINE
BE
COMPLETED BY APPLICANT.

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