Form Ds-5504 - Us Passport Re-Application Form (Page 4 of 6) in pdf

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.

PRIVACY ACT STATEMENT

AUTHORITIES: Collection of the information solicited on this form is authorized by Titles 8, 22, and 26 of the United States Code, whether

or not codified, including specifically 22 U.S.C. 211a et seq.; 26 U.S.C. 6039E, Section 236 of the Admiral James W. Nance and Meg

Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001; Executive Order 11295 (August 5, 1966); and 22 CFR parts 50

and 51.

PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to issuance of a U.S.

passport.

ROUTINE USES: The information solicited on this form may be made available as a routine use to other government agencies to assist

the U.S. Department of State in adjudicating passport applications and requests for related services, and for law enforcement 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. The information may be made available to private U.S.

citizen ‘wardens’ designated by the U.S. embassies and consulates. For a more detailed listing of the routine uses to which this

information may be put, see the Prefatory Statement of Routine Uses and the listing of routine users set forth in the system descriptions for

Overseas Citizen Services Records (State-05) and Passport Records (State-26) published in the Federal Register.

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: With the exception of your Social Security Number (see Federal Tax

Law statement on Instruction Page 3), you are not legally required to provide the information requested on this form. However, failure to

do so may result in Passport Services’ refusal to accept your application or result in the denial of a U.S. passport.

ELECTRONIC PASSPORT STATEMENT

The State Department will begin issuing a new type of passport containing an embedded electronic chip and called an “Electronic

Passport”. The new passport will continue to be proof of the bearer’s United States citizenship and identity, and will look and function in

the same way as a passport without a chip. The addition of an electronic chip in the back cover will enable the new passport to carry a

duplicate electronic copy of all information from the data page. The new passport will be usable at all ports-of-entry, including those that

do not yet have electronic chip readers.

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

at ports-of-entry equipped with electronic chip readers, the new passport will provide for faster clearance through some of the port-of-entry

processes.

Issuance of this new passport will be phased in incrementally. It is expected that by late-2006 nearly all U.S. passports will be issued in

this new format. The new passport will not require special handling or treatment, but like previous versions should be protected from

extreme bending and from immersion in water. The electronic chip must be read using specially formatted readers, and is not susceptible

to unauthorized reading.

The cover of the new passport will be printed with a special symbol representing the embedded chip. The symbol

will appear in port-of-entry areas where the electronic passport can be read.

NOTICE TO APPLICANTS FOR OFFICIAL, DIPLOMATIC, OR NO-FEE PASSPORTS

You may use this application if you meet all of the provisions listed on Instruction Page 2, however you must CONSULT YOUR

SPONSORING AGENCY FOR INSTRUCTIONS ON PROPER ROUTING PROCEDURES BEFORE FORWARDING THIS APPLICATION.

Your completed passport will be released to your sponsoring agency for forwarding to you.

DS-5504

Instruction Page 4 of 4

Form Ds-5504 - Us Passport Re-Application Form Page 4

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