Ds-64 - Statement Regarding A Lost Or Stolen U.s. Passport Book And Or Card (Page 2 of 2) in pdf

OMB CONTROL NO. 1405-0014

U.S. Department of State

OMB EXPIRATION DATE: 06/30/2018

ESTIMATED BURDEN: 10 Minutes

Please Print Legibly Using Black Ink Only

STATEMENT REGARDING A LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD

IMPORTANT NOTICE

A U.S. citizen may not normally bear more than one valid or potentially valid U.S. passport book and/or card at a time. Therefore, a statement is

required when applying for a new U.S. passport if the previously valid or potentially valid passport is not submitted. Your statement must detail why

the previous U.S. passport cannot be presented. The information you provide on this form will be placed into the Consular Lost and Stolen Passport

System, which is designed to prevent the misuse of all reported lost or stolen passports. If more than one U.S. passport previously issued to you

was lost or stolen, your replacement passport may be limited in validity. Once reported, the lost or stolen passport is electronically cancelled and

MUST NOT BE USED FOR TRAVEL. Anyone (including the bearer) traveling on a reported lost or stolen passport may be detained upon entering

the United States. Should you locate the passport after reporting it lost or stolen, submit it for cancellation to the Consular Lost and Stolen Unit. See

page one of this form for more information.

Please select the document (or documents) which you are reporting and its status.

Lost

U.S. Passport Book

U.S. Passport Card

Stolen

1. IDENTIFYING INFORMATION: Type or print legibly in 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 (City & State if in U.S. or City & Country)

Social Security Number

Sex

Female

Male

Current Address (Street, City, State, and ZIP Code)

Telephone Number

Alternative Telephone Number

E-mail Address

(

)

(

)

Answer all questions completely. If you do not know the

2. LOST OR STOLEN U.S. PASSPORT BOOK/CARD INFORMATION:

answer in detail, be as exact as possible.

Are you submitting this form in connection with an application for a new U.S. passport book and/or card?

Yes

Explain how your U.S. passport book/card was lost or stolen.

Did you file a police report?

Yes

Explain where the loss or theft occurred. Provide Address if known (City and State, if in the U.S., or City and Country as it is presently known)

On what date was your U.S. passport book/card lost or stolen? (mm-dd-yyyy). If unknown, when was the last time you remember it in your possession?

List your lost or stolen U.S. Passport Book:

List your lost or stolen U.S. Passport Card:

Issue

Number:

Date (mm/dd/yyyy)

Number:

Date: (mm/dd/yyyy):

Have you had any other U.S. passport book/card lost or stolen?

Yes

If yes, how many times?

Approximate time frame?

Did you file a police report?

Yes

3. YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW

I, the undersigned, declare under penalty of perjury all of the following: 1) That I have read and understood the warning on page one of this form;

2) The information furnished herein is correct and complete; 3) I have not given my U.S. passport book and/or passport card to another person or disposed of it in an

unauthorized manner; 4) I understand that the U.S. passport(s) I report as missing will be invalidated and cannot be used; and 5) if I subsequently find and recover it, I will

immediately return the passport and/or passport card to Passport Services at the address on page one of this form or to the nearest U.S. passport agency, U.S. embassy,

or U.S. consulate abroad.

Date (mm/dd/yyyy)

Legal Signature - age 16 or older or Parent/Guardian if under age 16

Date (mm/dd/yyyy)

Legal Signature - Parent/Guardian if under age 16

Both parents or guardians of a child younger than 16 years old must sign this form when submitting on the child's behalf unless one parent or guardian has sole custody. If

there is sole custody, include a copy of a supporting document, such as a court order, with this form.

DS-64 06-2015

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