Application For A U.s. Passport Corrections, Name Change Within 1 Year Of Passport Issuance, And Limited Passport Holders printable pdf download

APPLICATION FOR A U.S. PASSPORT

CORRECTIONS, NAME CHANGE WITHIN 1 YEAR OF PASSPORT ISSUANCE, AND LIMITED PASSPORT HOLDERS

PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS

Mailing Date of Application:____________________________

CAN I USE THIS FORM?

Complete this checklist to determine your eligibility to use this form

I have changed my name less than one year since my most recent U.S. passport

book and/or U.S. passport card was issued AND my U.S. passport book and/or

Yes

U.S. passport card is less than one year old;

My identifying information in my most recent U.S. passport book and/or U.S.

Yes

passport card was printed incorrectly;

My most recent U.S. passport book was limited to two years or less for a

Yes

reason other than multiple losses or a seriously damaged/mutilated passport.

If you answered NO to ALL of the three statements above,

STOP - You cannot use this form!

You must apply on application form DS-11 or DS-82 depending on your circumstances. Please refer to those forms, visit

travel.state.gov, or contact the National Passport Information Center for further information.

U.S. PASSPORTS, EITHER IN BOOK OR CARD FORMAT, ARE ISSUED ONLY TO U.S. CITIZENS OR NON-CITIZEN NATIONALS. EACH PERSON

MUST OBTAIN HIS OR HER OWN PASSPORT BOOK OR PASSPORT CARD. THE PASSPORT CARD IS A U.S. PASSPORT ISSUED IN CARD

FORMAT. LIKE THE TRADITIONAL PASSPORT BOOK, IT REFLECTS THE BEARER'S ORIGIN, IDENTITY, AND NATIONALITY AND IS SUBJECT TO

EXISTING PASSPORT LAWS AND REGULATIONS. UNLIKE THE PASSPORT BOOK, THE PASSPORT CARD IS VALID ONLY FOR ENTRY TO THE

UNITED STATES AT LAND BORDER CROSSINGS AND SEA PORTS OF ENTRY WHEN TRAVELING FROM CANADA, MEXICO, THE CARIBBEAN,

AND BERMUDA. THE U.S. PASSPORT CARD IS NOT VALID FOR INTERNATIONAL AIR TRAVEL.

INFORMATION, QUESTIONS, AND INQUIRIES

Please visit our website at travel.state.gov. In addition, you may contact the National Passport Information

Center (NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by email at NPIC@state.gov. Customer

Service Representatives are available Monday-Friday 8:00a.m.-10:00p.m. Eastern Time (excluding federal

holidays.) Automated information is available 24 hours a day, 7 days a week.

FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM, INCLUDING YOUR SOCIAL SECURITY NUMBER,

MAY RESULT IN SIGNIFICANT PROCESSING DELAYS AND/OR THE DENIAL OF YOUR APPLICATION.

NOTICE TO APPLICANTS RESIDING ABROAD

United States citizens residing outside the U.S. or Canada CANNOT submit this form to the domestic address listed on the Instruction Page 2. Such applicants

should contact the nearest U.S. Embassy or Consulate for procedures to be followed when applying overseas.

WARNING: False statements made knowingly and willfully in passport applications, including affidavits or other documents submitted to support

this application, are punishable by fine and/or imprisonment under U.S. law, including the provisions of 18 U.S.C. 1001, 18 U.S.C. 1542, and/or 18

U.S.C. 1621. 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 are subject to verification.

See page 2 of the instructions for detailed information on the completion and submission of this form.

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 additional information is required.

DS-5504 06-2016

Instruction Page 1 of 4