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8U.S. Department of State
STATEMENT REGARDING A LOST OR STOLEN PASSPORT
IMPORTANT NOTICE
A United States citizen may not normally bear more than one valid or potentially valid U.S. passport at a time. It
therefore is necessary to submit a statement with an application for a new U.S. passport when a previous valid
or potentially valid U.S. passport cannot be presented. Your statement must detail why the previous U.S.
passport cannot be presented.
The information you provide on the DS-64, Statement Regarding a Lost or Stolen Passport will be placed into our
Consular Lost or Stolen Passport System. This system is designed to prevent the misuse of your lost or stolen
U.S. passport. Anyone using the passport book reported on the DS-64 may be detained upon entry into the
United States. Should you locate the passport reported lost or stolen at a later time, you should report it as
found and submit it for cancellation. It has been invalidated. You may not use that passport for travel.
Protect yourself against identity theft!
Report a lost or stolen passport!
1. IDENTIFYING INFORMATION
Type or print in blue or black ink in white areas only
.
Last Name
First Name
Middle Name
Has your name changed since the passport was issued? If yes, state the name in which the lost or stolen passport was issued.
Date of Birth (mm-dd-yyyy) Place of Birth (State or Country)
Social Security Number
Female
SEX
Male
Current Address (Street, City, State, & Zip Code)
Home Telephone Number
Work Telephone Number
E-mail Address
(
)
(
)
Answer all questions completely. If you do not know the answer in detail, be as
2. LOST OR STOLEN PASSPORT INFORMATION
exact as possible. Additional space is provided on the back of this form.
What was your lost or stolen passport number?
When was your lost or stolen passport issued?
What passport agency, embassy, or consulate issued your lost or stolen passport?
How was your passport lost or stolen?
Where and on what date did the loss or theft take place?
If your passport was stolen, did you notify the police? If yes, explain when and where you notified the police.
Have you made any effort to recover your passport? If yes, describe your efforts.
Have you had any other U.S. passports lost or stolen?
(Please give the approximate date of this loss or theft and any additional information you can
provide.)
Are you submitting this form in connection with an application for a new passport?
Yes
No
CERTIFICATION
I, the undersigned, certify that the information furnished herein is correct and complete to
the best of my knowledge and belief, and that I have not given my passport to another person or disposed of it in
an unauthorized manner. I understand that my passport will be invalidated and cannot be used. If I subsequently
find and recover it, I will immediately return it to Passport Services at the address on the back of this form or to
the nearest passport agency.
Signature
Date (mm-dd-yyyy)
For Official Use Only
DS-64
Page 1 of 2
OMB No. 1405-0014 Expires: 12/31/2005
Estimated Burden 5 Minutes (See Page 2)
04-2003
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