Us Passport Application Form (Page 4 of 6) in pdf

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 for a federal or state drug offense or convicted for “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 the information solicited on this form is authorized by Titles 8, 22, and 26 of the United States Code, and other

applicable laws and regulations, including 22 USC 211a et seq.; 8 USC 1104; 26 USC 6039E, 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 CFR parts 50

and 51.

PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to issuance of a U.S. passport.

ROUTINE USES: The information solicited on this form may be made available as a routine use to other government agencies and private

contractors to assist the U.S. Department of State in adjudicating passport applications and requests for related services, and for law enforcement,

fraud prevention, border security, counterterrorism, litigation activities, and administrative purposes. The information may be made available to

foreign government agencies to fulfill passport control and immigration duties. The information may also be provided to foreign government

agencies, international organizations and, in limited cases, private persons and organizations to investigate, prosecute, or otherwise address

potential violations of law or to further the Secretary's responsibility for the protection of U.S. citizens and non-citizen nationals abroad. The

information may be made available to the Department of Homeland Security and private employers for employment verification purposes. For a

more detailed listing of the routine uses to which this information may be put see the Department of State's Prefatory Statement of Routine Uses

relative to the Privacy Act (Public Notice 6290 of July 15, 2008) and the listing of routine users set forth in the System of Records Notices for

Overseas Citizen Services Records (State-05) and Passport Records (State-26) published in the Federal Register.

Your social security numbers will be provided to the U.S. Department of Treasury and failure to provide it may subject you to a penalty, as

described in the Federal Tax Law provision. It also may be used for identification verification for passport adjudication and in connection with debt

collection, among other purposes as authorized and generally described in this section. Providing your social security number and other information

requested on this form otherwise is voluntary, but failure to provide the information requested on this form may result in processing delays or the

denial of your U.S. passport application.

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Failure to provide the information requested on this form may result in Passport

Services' refusal to accept your application or result in the denial of a U.S. passport.

ELECTRONIC PASSPORT STATEMENT

The Department of State now issues a type of passport book containing an embedded electronic chip and called an "Electronic Passport". The

electronic passport book continues to be proof of the bearer's United States 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.

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.

DS-5504 12-2010

Instruction Page 4 of 4

Us Passport Application Form Page 4

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