Statement Regarding A Lost Or Stolen Passport
ADVERTISEMENT
1
2OMB No. 1405-0014
Expires: 05-31-2011
U.S. Department of State
Estimated Burden: 5 Minutes*
STATEMENT REGARDING A LOST OR STOLEN PASSPORT
IMPORTANT NOTICE
A U.S. citizen may not normally bear more than one valid or potentially valid U.S. passport book and one valid passport
card at a time. It therefore is necessary to submit a statement with an application for a new U.S. passport when a
previously issued valid or potentially valid U.S. passport cannot be presented. Your statement must detail why the
previous U.S. passport cannot be presented. The information you provide on the DS-64, Statement Regarding a Lost
or Stolen Passport, will be placed into our Consular Lost or Stolen Passport System. This system is designed to
prevent the misuse of your lost or stolen U.S. passport. Anyone using the passport reported on the DS-64, including
yourself, may be detained upon entry into the United States. Should you locate the passport reported lost or stolen at
a later time, you should report it as found and submit it for cancellation. It has been invalidated. You may not use
that passport for travel. See page 2 of this form for additional information.
Protect yourself against identity theft! Report a lost or stolen passport book or passport card!
Please select the document (or documents) which you are reporting and its status.
Lost
Lost
U.S. Passport Card
U.S. Passport Book
Stolen
Stolen
1. IDENTIFYING INFORMATION
Type or print legibly in blue or black ink in white areas only.
Last Name
First Name
Middle Name
Has your name changed since the passport was issued? If yes, state the name in which the lost or stolen passport was issued.
Date of Birth (mm-dd-yyyy)
Place of Birth (State or Country)
Social Security Number
Female
Male
Sex
Current Address (Street, City, State, and ZIP Code)
Home Telephone Number
Work Telephone Number
E-mail Address
(
)
(
)
Answer all questions completely. If you do not know the answer in detail, be
2. LOST OR STOLEN PASSPORT INFORMATION
as exact as possible.
List your lost or stolen passport numbers:
List the date(s) your lost or stolen passport(s) were issued: (mm-dd-yyyy)
Passport
Passport
Passport
Passport
Book
Card
Book
Card
How, where and on what date did the loss or theft take place? If lost, what efforts were made to recover the passport?
If you have had any other U.S. passport lost or stolen, give the approximate date of this loss or theft and any additional information you can provide. If
the space provided is not sufficient to answer the question, please continue answering the question on a separate piece of paper.
Are you submitting this form in connection with an application for a new passport?
Yes
No
I, the undersigned, declare under penalty of perjury that the information furnished herein is correct and complete and
that I have not given my passport book and/or passport card to another person or disposed of it in an unauthorized
manner. I understand that my passport(s) will be invalidated and cannot be used. If I subsequently find and recover it, I
will immediately return it to Passport Services at the address on the back of this form or to the nearest passport agency.
(mm-dd-yyyy)
Signature
Date
For Official Use Only
DS-64
Page 1 of 2
03-2009
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life