Form Ds11 - Application For Us Passport Or Registration Page 4


U.S. Department of State
26 U.S.C. 6039E (Internal Revenue Code) requires a passport applicant to provide his or her name and social security
number. If you have not been issued a social security number, enter zeros in box #6. The U.S. Department of State must
provide this information to the Internal Revenue Service routinely.
Any applicant who fails to provide the required
information is subject to a $500 penalty enforced by the IRS. All questions on this matter should be referred to the
nearest IRS office.
(If any of the below-mentioned acts or conditions has 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, 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.
WARNING: False statements made knowingly and willfully in passport applications or in affidavits or other supporting
documents submitted therewith are punishable by fine and/or imprisonment under provisions of 18 U.S.C. 1001 and/or 18
U.S.C. 1542.
Alteration or mutilation of a passport issued pursuant to this application is punishable by fine and/or
imprisonment under the provisions of 18 U.S.C. 1543. The use of a passport in violation of the restrictions contained
therein or of the passport regulations is punishable by fine and/or imprisonment under 18 U.S.C. 1544. All statements
and documents submitted are subject to verification.
AUTHORITIES: The information solicited on this form is requested pursuant to provisions in Titles 8, 18, and 22 of the
United States Code, whether or not codified, including specifically 22 U.S.C. 211a, 212, and 213, and all regulations
issued pursuant to Executive Order 11295 (August 5, 1966), including Part 51, Title 22, Code of Federal Regulations
(CFR). Also, as noted, 26 U.S.C. 6039E.
PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to
issuance of a U.S. passport. The information may also be used in connection with issuing other travel documents or
evidence of citizenship, and in furtherance of the Secretary's responsibility for the protection of U.S. nationals abroad.
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 for law enforcement and
administration purposes. It may also be disclosed pursuant to court order. The information may be made available to
foreign government agencies to fulfill passport control and immigration duties or to investigate or prosecute violations of
law. The information may also be made available to private U.S. citizen 'wardens' designated by U.S. Embassies and
Failure to provide the information requested on this form may result in the denial of a United States passport, related
document, or service to the individual seeking such passport, document, or service.
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time
required for searching existing data sources, gathering the necessary data, providing the information required, and
reviewing the final collection. You do not have to provide the information unless this collection displays a currently valid
OMB number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to:
U.S. Department of State (A/RPS/DIR) Washington, DC 20520.
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