Statement Of Non-Receipt Of A U.s. Passport (Page 2 of 2) in pdf

HOW TO USE THIS FORM

To determine how and when to use this form, please call the National Passport

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

This form must be mailed to the passport agency that originally processed your

application. To obtain the address of that agency, please call NPIC at the number above.

For more information, please visit our website at travel.state.gov.

WARNING

False statements made knowingly and willfully in passport applications, or in affidavits, or other

supporting documents submitted therewith are punishable by fine and/or imprisonment under the

provisions of 18 U.S.C. 1001, 18 U.S.C. 1542, and/or 18 U.S.C. 1621. Alteration or mutilation of a

U.S. passport issued pursuant to this application is punishable by fine and/or imprisonment under

the provisions of 18 U.S.C. 1543. The use of a U.S. passport in violation of the restrictions

contained therein or of the passport regulations is punishable by fine and/or imprisonment under 18

U.S.C. 1544. All statements and documents are subject to verification.

PRIVACY ACT STATEMENT

AUTHORITIES: The information on this form is requested under the authority of 22 U.S.C. 211a et

seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E; Executive Order 11295 (August 5, 1966); and 22 C.F.R.

parts 50 and 51.

PURPOSE: The information collected on this form will be used to determine whether to issue you a

replacement U.S. passport.

The collection of the Social Security number will be used for

identity/entitlement to passport verification only and no other purpose unless authorized by law.

ROUTINE USES: This information may be disclosed to another domestic government agency, a

private contractor, a foreign government agency, or to a private person or private employer in

accordance with certain approved routine uses. These routine uses include, but are not limited to,

law

enforcement

activities,

employment

verification,

fraud

prevention,

border

security,

counterterrorism, litigation activities, and activities that meet the Secretary of State's responsibility

to protect U.S. citizens and non-citizen nationals abroad.

More information on the Routine Uses for the system can be found in System of Records Notices

State-05, Overseas Citizen Services Records and State-26, Passport Records.

DISCLOSURE: Providing your Social Security number and the other information on this form is

voluntary, but failure to provide the information on this form may, given the form's purpose of

verification of your identity or entitlement, result in processing delays or denial of your passport

application.

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 15 minutes per

response, including time required for searching existing data sources, gathering the necessary

data, providing the information and/or documentation required, and reviewing the final collection.

You do not have to supply this information unless the 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 U.S. Department of State, Bureau of

Consular Affairs, Passport Services, Office of Program Management and Operational Support,

2201 C Street, NW, Washington, DC 20520.

DS-86

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Statement Of Non-Receipt Of A U.s. Passport Page 2

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