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ACTS OR CONDITIONS

If any of the below-mentioned acts or conditions have been performed by or apply to the applicant, the portion which applies should be lined out,

and a supplementary explanatory statement under oath (or affirmation) by the applicant should be attached and made a part of this application.

I have not, since acquiring United States citizenship/nationality, been naturalized as a citizen of a foreign state; taken an oath or made an

affirmation or other formal declaration of allegiance to a foreign state; entered or served in the armed forces of a foreign state; accepted or

performed the duties of any office, post, or employment under the government of a foreign state or political subdivision thereof; made a formal

renunciation of nationality either in the United States, or before a diplomatic or consular officer of the United States in a foreign state; or been

convicted by a court or court martial of competent jurisdiction of committing any act of treason against, or attempting by force to overthrow, or

bearing arms against, the United States, or conspiring to overthrow, put down, or to destroy by force, the government of the United States.

Furthermore, I have not been convicted of a federal or state drug offense or convicted for "sex tourism" crimes statute, and I am not the subject of

an outstanding federal, state, or local warrant of arrest for a felony; a criminal court order forbidding my departure from the United States; a

subpoena received from the United States in a matter involving federal prosecution for, or grand jury investigation of, a felony.

PRIVACY ACT STATEMENT

AUTHORITIES: We are authorized to collect this information by 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: We are requesting this information in order to determine your entitlement to receive the passport service for which you are applying.

The collection of the Social Security number will be used for identity/entitlement 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 application.

ELECTRONIC PASSPORT STATEMENT

The U.S. Department of State now issues an "Electronic Passport" book, which contains an embedded electronic chip. The electronic passport

book continues to be proof of the bearer's United States citizenship/nationality and identity, and looks and functions in the same way as a passport

without a chip. The addition of an electronic chip in the back cover enables the passport book to carry a duplicate electronic copy of all information

from the data page. The electronic passport book is usable at all ports-of-entry, including those that do not yet have electronic chip readers.

Use of the electronic format provides the traveler the additional security protections inherent in chip technology. Moreover, when used at

ports-of-entry equipped with electronic chip readers, the electronic passport book provides for faster clearance through some of the port-of-entry

processes.

The electronic passport book does not require special handling or treatment, but like previous versions, should be protected from extreme heat,

bending, and from immersion in water. The electronic chip must be read using specially formatted readers, which protects the data on the chip from

unauthorized reading.

The cover of the electronic passport book is printed with a special symbol representing the embedded chip. The symbol

will appear in

port-of-entry areas where the electronic passport book can be read.

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time required for searching

existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection. You

do not have to supply this information unless this 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, D.C. 20520.

DS-4085 08-2013

Instruction Page 3 of 3

Form Ds-4085 - Omb Application Form For Additional Visa Pages Or Miscellaneous Passport Services Page 3

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