Us Passport Application Form (Page 3 of 6) in pdf

FEDERAL TAX LAW

Section 6039E of the Internal Revenue Code (26 USC 6039E) requires you to provide your Social Security Number (SSN), if you have one, when

you apply for a U.S. passport or renewal of 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 Department of State must provide your SSN

and foreign residence information to the 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 USC 214, 22 CFR 22.1, and 22 CFR 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 Department of State will take action to collect the delinquent

fees from you under 22 CFR Part 34 and the Federal Claims Collection Standards (see 31 CFR 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 Department of Treasury for collection. Debt collection procedures used by 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 NUMBERS

Your Social Security Number will be provided to 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.

PAPERWORK REDUCTION STATEMENT

Public reporting burden for this collection of information is estimated to average 30 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: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State,

Washington, DC 20520-2202.

IMPORTANT NOTICE TO APPLICANTS WHO HAVE LOST OR HAD A PREVIOUS PASSPORT BOOK

AND/OR PASSPORT CARD STOLEN

A United States citizen may not normally bear more than one valid or potentially valid U.S. passport book or more than one valid or potentially valid

U.S. passport card at a time. Therefore, when a valid or potentially valid U.S. passport book or U.S. passport card cannot be presented with a new

application, it is necessary to submit a Form DS-64, Statement Regarding a Lost or Stolen Passport. Your statement must detail why the previous

U.S. passport book or U.S. passport card cannot be presented.

The information you provide regarding your lost or stolen U.S. passport book or passport card 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 book or passport card. Anyone using the

passport book or passport card reported as lost or stolen may be detained upon entry into the United States. Should you locate the U.S. passport

book or passport card reported lost or stolen at a later time, report it as found and submit it for cancellation. It has been invalidated. You may not

use that passport book or passport card for travel.

PROTECT YOURSELF AGAINST IDENTITY THEFT!

REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD!

For more information or to report your lost or stolen passport book or passport card by phone, call NPIC or visit our website at travel.state.gov.

DS-5504 12-2010

Instruction Page 3 of 4