Form Ds-11 - Application Form For A U.s. Passport (Page 3 of 6) in pdf

NOTE REGARDING MAILING ADDRESSES

Passport Services will not mail a U.S. passport to a private address outside the United States. If you do not live at the address listed in the "mailing address",

then you must put the name of the person and mark it as "In Care Of" in item # 8. If your mailing address changes prior to receipt of your new passport,

please contact the National Passport Information Center.

If you choose to provide your email address in Item #6 on this application, Passport Services may use that information to contact you in the event there is a

problem with your application or if you need to provide information to us.

FEDERAL TAX LAW

Section 6039E of the Internal Revenue Code (26 U.S.C. 6039E) requires you to provide your Social Security number (SSN), if you have one, when

you apply for or renew a U.S. passport. If you have not been issued a SSN, enter zeros in box #5 of this form. If you are residing abroad, you must

also provide the name of the foreign country in which you are residing. The U.S. Department of State must provide your SSN and foreign residence

information to the U.S. Department of Treasury. If you fail to provide the information, you are subject to a $500 penalty enforced by the IRS. All

questions on this matter should be directed to the nearest IRS office.

NOTICE TO CUSTOMERS APPLYING OUTSIDE A STATE DEPARTMENT FACILITY

If you send us a check, it will be converted into an electronic funds transfer (EFT). This means we will copy your check and use the account

information on it to electronically debit your account for the amount of the check. The debit from your account will usually occur within 24 hours and

will be shown on your regular account statement.

You will not receive your original check back. We will destroy your original check, but we will keep the copy of it. If the EFT cannot be processed for

technical reasons, you authorize us to process the copy in place of your original check. If the EFT cannot be completed because of insufficient

funds, we may try to make the transfer up to two times, and we will charge you a one-time fee of $25, which we will also collect by EFT.

REMITTANCE OF FEES

Passport service fees are established by law and regulation (see 22 U.S.C. 214, 22 C.F.R. 22.1, and 22 C.F.R. 51.50-56), and are collected at the

time you apply for the passport service. If the Department fails to receive full payment of the applicable fees because, for example, your check is

returned for any reason or you dispute a passport fee charge to your credit card, the U.S. Department of State will take action to collect the

delinquent fees from you under 22 C.F.R. Part 34, and the Federal Claims Collection Standards (see 31 C.F.R. Parts 900-904). In accordance with

the Debt Collection Improvement Act (Pub.L. 104-134), if the fees remain unpaid after 180 days and no repayment arrangements have been made,

the Department will refer the debt to the U.S. Department of Treasury for collection. Debt collection procedures used by U.S. Department of

Treasury may include referral of the debt to private collection agencies, reporting of the debt to credit bureaus, garnishment of private wages and

administrative offset of the debt by reducing, or withholding eligible federal payments (e.g., tax refunds, social security payments, federal retirement,

etc.) by the amount of your debt, including any interest penalties or other costs incurred. In addition, non-payment of passport fees may result in the

invalidation of your passport. An invalidated passport cannot be used for travel.

OTHER USES OF SOCIAL SECURITY NUMBER

Your Social Security number will be provided to U.S. Department of Treasury, used in connection with debt collection and checked against lists of

persons ineligible or potentially ineligible to receive a U.S. passport, among other authorized uses.

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.

PROTECT YOURSELF AGAINST IDENTITY THEFT!

REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD!

For more information regarding reporting a lost or stolen U.S. passport book or passport card and the Form DS-64,

your eligibility to submit a Form DS-82 or how to request additional visa pages, call NPIC at 1-877-487-2778 or

visit travel.state.gov.

SPECIAL NOTICE TO U.S. PASSPORT CARD APPLICANTS ONLY

The maximum number of letters provided for your given name (first and middle) on the U.S. passport card is 24 characters. The 24 characters may be

shortened due to printing restrictions. If both your given names are more than 24 characters, you must shorten one of your given names you list on item 1 of

this form.

DS-11 09-2013

Instruction Page 3 of 4

Form Ds-11 - Application Form For A U.s. Passport Page 3

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