Statement Of Non-Receipt Of A U.s. Passport printable pdf download

U.S. Department of State

OMB Approval No. 1405-0146

STATEMENT OF NON-RECEIPT OF A U.S. PASSPORT

Expiration Date: 09-30-2017

Estimated Burden: 15 Minutes

IMPORTANT NOTICE

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

passport card at a time. You have 90 days from the date that your passport document(s) was issued to report that you

have not yet received it in the mail. If you do not report the non-receipt of your U.S. passport document(s) within

90 days of the issue date, you will be required to reapply and submit the full passport fee(s). To check the status

of your U.S. passport application, please visit travel.state.gov or contact our National Passport Information Center

(NPIC) 1-877-487-2778 (TDD: 1-888-874-7793).

The information that you provide on the DS-86, Statement of Non-Receipt of a U.S. Passport, will be entered into the

Consular Lost or Stolen Passport System. Anyone using the U.S. passport book or U.S. passport card reported on the

DS-86, including yourself, may be detained. Should you receive the document you reported as not received at a later

time, report it as found and submit it for cancellation. It has been invalidated. You may not use it for travel. See page

two of this form for additional information.

This application must be accompanied by a clear photocopy of the

front and back of an identification document containing your photograph.

Protect yourself against identity theft! Report the non-receipt of your U.S. passport book or U.S. passport card!

Type or print legibly in black ink in the white areas only.

Please select the document(s) which you are reporting.

U.S. Passport Book

U.S. Passport Card

Last Name

First Name

Middle Name

Social Security Number

Primary Telephone Number

Secondary Telephone Number

Travel Date

Date of Birth

(mm-dd-yyyy)

Mailing Address

Street Address

Apartment /Unit

City

State

ZIP Code

I, the undersigned, certify that I have not received the U.S. passport book and/or U.S. passport card for which I applied. I declare under penalty of

perjury that the statements made on this form are true and correct. I request that a new U.S. passport book and/or U.S. passport card be issued to me,

and certify that if I receive the U.S. passport book and/or U.S. passport card for which I previously applied, I will immediately contact the National

Passport Information Center at 1-877-487-2778 (TDD: 1-888-874-7793) and return the recovered passport to the U.S. Department of State.

Applicant's Signature (age 16 and older)

Mother/Father/Parent/Legal Guardian's Signature (if applicant is under age 16)

Date (mm-dd-yyyy)

PASSPORT OFFICE USE ONLY

Was delivery confirmed?

Yes

Was the passport mailed to the correct mailing address?

Fed Ex

Tracking Number:

Vendor:

USPS