Form Ds-11 - Application For A Us Passport (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, 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 USC 211 a et seq.; 26 USC 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

US passport.

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

assist the US 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 US citizens and non-citizen nationals abroad. The information may be

made available to private US citizen ‘wardens’ designated by the US 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 US passport.

ELECTRONIC PASSPORT STATEMENT

Early in 2005, 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 during an 18-month period. It is expected that by mid-2006 nearly all US 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 “LOGO IMAGE”

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-11

Instruction Page 4 of 4

Form Ds-11 - Application For A Us Passport Page 4

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