Form Ds-5504 - Us Passport Re-Application Form Page 6
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6Name of Applicant
Date of Birth
(Last, First, Middle)
(mm/dd/yyyy)
Please complete the following questions.
TO USE THIS FORM, YOUR CURRENT PASSPORT MUST BE LESS THAN ONE YEAR OLD.
If yes, complete section A below.
19. Has your name changed since your most recent passport was issued?
Y
N
If yes, complete section B below.
20. Was your identifying information printed incorrectly in your passport?
Y
N
If yes, submit citizenship
21. Was your most recent passport limited for one year and/or issued abroad?
Y
N
evidence. Sign and date below.
SECTION A—NAME CHANGES
(Submit original or certified documents only)
CHANGE NAME TO READ AS FOLLOWS:
Last
First / Middle
IF YES, give date of marriage.
WAS YOUR NAME CHANGED BY MARRIAGE?
Y
N
(mm/dd/yyyy)
What was your spouse’s full name at his/her time of birth?
Last
First / Middle
WAS YOUR NAME CHANGED BY COURT ORDER?
Y
N
IF YES, give date of court order.
(mm/dd/yyyy)
Name of court
Location of court (City, State)
SECTION B—PERSONAL INFORMATION CORRECTIONS
(Submit original or certified documents only.)
ATTENTION:
COMPLETE ONLY THE SECTIONS THAT WERE PRINTED INCORRECTLY IN YOUR
RECENTLY ISSUED U.S. PASSPORT.
Name
Last
Suffix
First
Middle
(Jr., Sr., III)
Date of Birth
Place of Birth
Sex
Male
Female
(mm/dd/yyyy)
(City & State OR City & Country)
OATH AND SIGNATURE
I declare under penalty of perjury that I am a United States citizen (or non-citizen national) and have not, since acquiring United States
citizenship (or U.S. nationality), performed any of the acts listed under “Acts or Conditions” on the reverse of this application form (unless
explanatory statement is attached). I declare under penalty of perjury that the statements made on this application are true and correct.
Date (mm/dd/yyyy)
Signature of Applicant
FOR PASSPORT SERVICES USE ONLY
— Adjudication Notes —
Evidence
Name Change
Rewrite / Reissue
Other
Endorsement No.
Limit To
APPLICATION APPROVAL
FEE _____________ EF ______________ OTHER _____________
DS-5504
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