Form Ds-11 - Application For A U.s. Passport (Page 4 of 6) in pdf

ELECTRONIC PASSPORT STATEMENT

The U.S. Department of State now issues an "Electronic Passport" book, which contains an embedded electronic chip. The electronic passport

book continues to be proof of the bearer's U.S. citizenship/nationality and identity, and looks and functions in the same way as a passport without a

chip. The addition of an electronic chip in the back cover enables the passport book to carry a duplicate electronic copy of all information from the

data page. The electronic passport book is usable at all ports-of-entry, including those that do not yet have electronic chip readers.

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

ports-of-entry equipped with electronic chip readers, the electronic passport book provides for faster clearance through some of the port-of-entry

processes.

The electronic passport book does not require special handling or treatment, but like previous versions should be protected from extreme heat,

bending, and from immersion in water. The electronic chip must be read using specially formatted readers, which protects the data on the chip

from unauthorized reading.

The cover of the electronic passport book is printed with a special symbol representing the embedded chip. The symbol

will appear in

port-of-entry areas where the electronic passport book can be read.

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.

Furthermore, I have not been convicted of a federal or state drug offense or convicted of a "sex tourism" crimes statute, and I am not the subject of

an outstanding federal, state, or local warrant of arrest for a felony; a criminal court order forbidding my departure from the United States; a

subpoena received from the United States in a matter involving federal prosecution for, or grand jury investigation of, a felony.

PRIVACY ACT STATEMENT

AUTHORITIES: Collection of this information is authorized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E, 22 U.S.C. 2714a(f),

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 C.F.R. parts 50 and 51.

PURPOSE: We are requesting this information in order to determine your eligibility to be issued a U.S. passport. Your Social Security number is

used to verify your identity.

ROUTINE USES: This information may be disclosed to another domestic government agency, a private contractor, a foreign government agency,

or to a private person or private employer in accordance with certain approved routine uses. These routine uses include, but are not limited to, law

enforcement activities, employment verification, fraud prevention, border security, counterterrorism, litigation activities, and activities that meet the

Secretary of State's responsibility to protect U.S. citizens and non-citizen nationals abroad. More information on the Routine Uses for the system

can be found in System of Records Notices State-05, Overseas Citizen Services Records and State-26, Passport Records.

DISCLOSURE: Providing information on this form is voluntary. Be advised, however, that failure to provide the information requested on this form

may cause delays in processing your U.S. passport application and/or could result in the refusal or denial of your application.

Failure to provide your Social Security number may result in the denial of your application (consistent with 22 U.S.C. 2714a(f)) and may subject you

to a penalty enforced by the Internal Revenue Service, as described in the Federal Tax Law section of the instructions to this form. Your Social

Security number will be provided to the Department of the Treasury and may be used in connection with debt collection, among other purposes

authorized and generally described in this section.

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 85 minutes per response, including the time required for searching

existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection. You

do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy

of this burden estimate and/or recommendations for reducing it, please send them to: U.S. Department of State, Bureau of Consular Affairs,

Passport Services, Office of Legal Affairs and Law Enforcement Liaison, 44132 Mercure Cir, P.O. Box 1227, Sterling, Virginia 20166-1227

DS-11 06-2016

Instruction Page 4 of 4

Form Ds-11 - Application For A U.s. Passport Page 4

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