Application for a U.S. Passport
U.S. Department of State
APPLICATION FOR A U.S. PASSPORT
PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS.
I applied: Place:
Date:
U.S. PASSPORTS ARE ISSUED ONLY TO U.S. CITIZENS OR NATIONALS. EACH PERSON MUST OBTAIN HIS OR HER OWN PASSPORT.
APPLICANTS WHO HAVE HAD A PREVIOUS US PASSPORT
If your most recent passport was issued less than 15 years ago and you were over 16 years old at the time of
issuance, you may be eligible to use Form DS-82 (mail-in application), Please inquire about eligibility when you
apply or visit our website or contact NPIC. Address any requests for addition of visa pages to a Passport Agency
or a U.S. consulate or embassy abroad. In advance of your departure, check visa requirements with consular
officials of the countries you will be visiting.
WHAT TO SUBMIT WITH THIS FORM:
1. PROOF OF U.S. CITIZENSHIP
2. PROOF OF IDENTITY
3. TWO RECENT, COLOR PHOTOGRAPHS, AND
4. FEES (As explained on reverse of form.)
WHERE TO SUBMIT THIS FORM:
Please complete and submit this application in person to one of the following acceptance agents: a clerk of a
Federal, State, or County Court of record or a judge or clerk of a probate court accepting applications; a
designated municipal or county official; a designated postal employee at an authorized post office; or an
agent at a Passport Agency in Boston, Chicago, Honolulu, Houston, Los Angeles, Miami, New Orleans, New
York, Norwalk CT, Philadelphia, San Francisco, Seattle, or Washington DC; or a U.S. consular official at a
U.S. embassy or consulate, if abroad. To find your nearest acceptance facility, visit our website or contact
the National Passport Information Center.
See Instruction Page 2 for detailed information on the completion and submission of this Form.
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Instruction Page , of 4
1. PROOF OF U.S. CITIZENSHIP
a. APPLICANTS BORN IN THE UNITED STATES: Submit a frevious U.S. passport or certified birth certificate. A birth certificate must
include your given name and surname, date, and place 0 birth, date the birth reco~i1ed, and the seal or other certification of the
official custodian of such records.
(1) If the birth certificate was filed more than 1 year after the birth: It is acceptable if it is supported by evidence described in the next
paragraph.
(2) If no birth record exists: Submit reJ:jistrar's notice to that effect. Also submit an early baPtismal or circumcision certificate,
hospital birth record, early census, school, or family Bible records, newspapers or insurance files, or notarized affidavits of persons
having knowledge of your birth (in addition to at least one record listed above). Evidence should include your given name and
surname, date and place of birth, and the seal or other certification of the issuing office (if customary) and the signature of the
issuing official.
b. APPLICANTS BORN OUTSIDE THE UNITED STATES: Submit a previous U.S. passport, Certificate of Naturalization, Certificate of
Citizenship, Consular Report of Birth Abroad, Q! evidence described below.
11) If You Claim Citizenshio Throueh Naturalization of ParentIs): Submit the Certificate(s) of Naturalization of your parentIs), your
foreign birth certificate, .!!!!.!! proof of your admission to the United States for permanent residence.
12) If You Claim Citizenship Through Birth Abroad to One U.S. Citizen Parent: Submit a Consular Report of Birth (Form FS-240).
Certification of Birth (Form DS-1350 or FS-545). or your foreign birth certificate, proof of citizenship of your parent, .ailll an
affidavit showing all of your U.S. citizen parent's periods and places of residence/physical presence in the United States and
abroad before your birth.
(3) If You Claim Citizenship Through Birth Abroad to Two U.S. Citizen Parents: Submit a Consular Report of Birth (Form FS-240).
Certification of Birth (Form DS-1350 or FS-545). or your foreign birth certificate, parent's marriage certificate, proof of citizenship
of your parentIs). and an affidavit showing all of your U.S. citizen parent's periods and places of residence/physical presence in the
United States and abroad before your birth.
(4) If You Claim Citizenship ThrouQh AdOPtion by a U.S. CitizenParent(s): Submit evidence of your permanent residence status, full
and final adoption, and your U.S. citizen parentIs) evidence of legal and physical custody. (Please note: Acquisition of U.S.
citizenship for persons born abroad or adopted only applies if the applicant was born on or after 02/27/1983)
c. ADDITIONAL EVIDENCE: When necessary, we may ask you to provide additional evidence to establish you claim to U.S. citizenship.
2. PROOF OF IDENTITY
You must establish your identity to the satisfaction of the acceptance agent.
You may submit items such as the following containing your signature AND physical description or photograph that is a good likeness of
you: previous U.S. passport, Certificate of Naturalization, Certificate of Citizenship, driver's license (not temporary or learner's license).
or government (Federal, State, municipal) employee identification card or pass. Temporary or altered documents are not acceptable.
When necessary, we may ask you to provide additional evidence to establish your identity.
IF YOU CANNOT PROVIDE DOCUMENT EVIDENCE OF IDENTITY as stated above, you must appear with an IDENTIFYING WITNESS who
is a U.S. citizen, non U.S. citizen national, or permanent resident alien who has known you for at least 2 years. Your witness must prove
his or her identity and complete and sign an Affidavit of Identifying Witness (Form DS-71) before the acceptance agent. You must also
submit some identification of your own.
3. TWO RECENT, COLOR PHOTOGRAPHS
Submit two color photographs of you alone, sufficiently recent to be a good likeness of you (normally taken within the last six months).
and 2x2 inches in size. The image size measured from the bottom of your chin to the top of your head (including hair) should not be less
than 1 inch and not more than 1-3/8 inches. The photographs must be color, clear, with full front view of your face, and printed on thin
paper with plain light (white or off-white) background. They must be capable of withstanding a mounting temperature of 225 Fahrenheit
(107 Celsius). Photographs must be taken in normal street attire, without a hat, head covering, or dark glasses unless a signed statement
is submitted by the applicant verifying the item is worn daily for religious purposes or a signed doctor's statement is submitted verifying
the item is used daily for medical purposes. Photographs retouched so that your appearance is changed are unacceptable. Snapshots,
most vending machine prints, and magazine or full-length photographs are unacceptable. Digitized photos must meet the previously
stated qualifications and will be accepted for use at the discretion of Passport Services. (Visit our website for details.)
4. FEES
a. If you are 16 years of age or older: The passport processing fee is $55, the application execution fee is $30, and the security surcharge
is $12 therefore your total cost for the passport will be $97. Your passport will be valid for 10 years from the date of issue except where
limited by the Secretary of State to a shorter period. (See information below about the additional cost for expedited service.)
b. If you are 15 years of aQe or younQer: The passport processing fee is $40, the application execution fee is $30, and the security
surcharge is $12, therefore your total cost for the passport will be $82. Your passport will be valid for 5 years from the date of issue
except where limited by the Secretary of State to a shorter period. (See information below about the additional cost for expedited
service.)
BY LA W, THE PASSPORT PROCESSING, EXECUTION, AND SECURITY FEES ARE NON.REFUNDABLE.
. The passport processing, execution, and security fees may be paid in one of the following forms: Checks (personal, certified, traveler's);
major credit card (Visa, Master Card, American Express, and Discover); bank draft or cashier's check; money order (U.S. Postal,
international, currency exchange). or if abroad, the foreign currency equivalent; or a check drawn on a U.S. bank. All fees should be
payable to the "U.S. Department of State", or if abroad, the appropriate U.S. embassy or consulate. When applying at a designated
acceptance facility, the $30 execution fee should be made payable to the acceptance facility. NOTE: Some designated acceptance
facilities do not accept credit cards as a form of payment.
. For faster processing, you may request expedited service. Exoedited reouests will be processed in three workdavs from receiot at a
oassoort aeencv. The additional fee for expedited service is $60. Therefore, if you choose to request expedited service and you are 16
years of age or older the total cost of your U.S. passport will be $157 and if you are 15 years of age or younger the total cost of your
U.S. passport will be $142. Expedited service is available only in the United States.
. If you desire SPECIAL POSTAGE SERVICE (overnight mail, special delivery, etc.). include the appropriate postage fee with your payment.
. An additional $60 fee will be charged when, upon your request, the U.S. Department of State verifies issuance of a previous U.S.
passport or Consular Report of Birth Abroad because you are unable to submit evidence of U.S. citizenship.
. For applicants with U.S. Government or military authorization for no.fee passports, no fees are charged, except the execution fee when
applying at a designated acceptance facility.
. If you choose to provide your e-mail address in Item #12 on this application, Passport Services will only use that information to contact
you in the event there is a problem with your application or if you need to provide additional information to us.
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Instruction Page 2 of 4
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 U.S. 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.
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.
31 USC 7701 requires persons "doing business" with a federal agency to provide their social security numbers to
that agency. Because the U.S. Department of State collects fees for the provision of passport services to you,
you are considered a person "doing business" with the Department. Passport service fees are established by law
and regulation (see 22 USC 214, 22 CFR 22.1, and 22 CFR 51.61-66) 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 U.S.
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 will result in the invalidation of your passport. An invalidated passport
cannot be used for travel.
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In addition to reporting your Social Security Number to Treasury and using it in connection with debt collection,
the Department checks Social Security Numbers against lists of persons ineligible or potentially ineligible to
receive a U.S. passport.
You are not required to provide the information requested on this form unless the form displays a currently valid
OMS number. We try to create forms and instructions that can be easily understood, Often this is difficult to do
because our citizenship laws are very complex. The estimated burden time for this information collection is 85
minutes, which includes the time required to search existing data sources, gather the necessary data, complete
and review this form, and provide and submit the form and any additional information required. If you have
comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we would
be happy to hear from you. You can write us at: U.S. Department of State (A/RPS/DIR), Washington, DC
20520.
A United States citizen may not normally bear more than one valid or potentially valid U.S. passport at a time. It
therefore is necessary to submit a statement with an application for a new U.S. passport when a previous valid or
potentially valid U.S. passport cannot be presented with an application for a new passport. Your statement must
detail why the previous U.S. passport cannot be presented.
The information you provide regarding your lost or stolen U.S. passport 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.
Anyone using the passport book reported as lost or stolen may detained upon entry into the United States,
Should you locate the U.S. passport 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 for travel.
PROTECT YOURSELF AGAINST IDENTITY THEFT - REPORT YOUR LOST OR STOLEN PASSPORT!
For more information or to report your lost or stolen passport by phone, call NPIC or visit our website at
www.travel.state.gov .
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Instruction Page 3 of 4
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(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, 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.
AUTHORITIES: Collection of the information solicited on this form is authorized by Titles 8, 22, and 26 of the
United States Code, whether or not codified, including specifically 22 USC 211 a et seq.; 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 to assist the U.S. Department of State in adjudicating passport applications and requests for
related services, and for law enforcement and administration 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 private U.S. citizen 'wardens' designated by the U.S. embassies and consulates. For a
more detailed listing of the routine uses to which this information may be put, see the Prefatory Statement of
Routine Uses and the listing of routine users set forth in the system descriptions for Overseas Citizen Services
Records (5tate-05) and Passport Records (State-26) published in the Federal Register.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: With the exception of your Social Security Number
(see Federal Tax Law statement on Instruction Page 3), you are not legally required to provide the information
requested on this form. However, failure to do so may result in Passport Services' refusal to accept your
application or result in the denial of a U.S. passport.
Early in 2005, the U.S. Department of State will begin issuing a new type of passport containing an embedded
electronic chip and called an "Electronic Passport". The new passport will continue to be proof of the bearer's
United States citizenship and identity, and will look and function in the same way as a passport without a chip.
The addition of an electronic chip in the back cover will enable the new passport to carry a duplicate electronic
copy of all information from the data page. The new passport will be usable at all ports-of-entry, including those
that do not yet have electronic chip readers.
Use of the electronic format will provide the traveler the additional security protections inherent in chip
technology. Moreover, when used at ports-of-entry equipped with electronic chip readers, the new passport will
provide for faster clearance through some of the port-of-entry processes.
Issuance of this new passport will be phased in during an 18-month period. It is expected that by mid-2006
nearly all U.S. passports will be issued in this new format. The new passport will not require special handling or
treatment, but like previous versions should be protected from extreme bending and from immersion in water.
The electronic chip must be read using specially formatted readers, and is not susceptible to unauthorized reading.
The cover of the new passport will be printed with a special symbol representing the embedded chip. The symbol
"LOGO IMAGE" will appear in port-of-entry areas where the electronic passport can be read.
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.
Instruction Page 4 of 4
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U.S. Department of State
APPLICATION FOR A US PASSPORT
OMB APPROVAL NO. 1406-0004
EXPIRATION DATE: 06/30/2006
ESTIMATED BURDEN: B6 Minut.s
ISee Instruction Page 3)
WARNING: False statements made knowingly and willfully in passport
applications. including affidavits or other supporting documents submitted
therewith. are punishable by fine andlor imprisonment under provisions of 18 USC
1001, and 18 USC 1542. Alteration or mutilation of a passport issued pursuant to
this application is punishable by fine andlor imprisonment under the provisions of (
18 USC 1543. The use of a passport in violation of the restrictions contained _
therein or of the passport regulations is punishable by fine andlor imprisonment
under 18 USC 1544. All statements and documents are subject to verification.
J
D 10 Yr. Issue
Date
Do DDP
Exp.
Street I RFD # OR Post Office Box
Apartment #
'"
x
N
Country (If outside the US;
City
Zip Code
N
X
";
Street I RFD # (DO NOT LIST P.O. BOX;
Apartment #
DS-11
03-2005
Page 1 of 2
NAME OF APPLICANT (Last, First, Middle)
22. Emergency Contact. Provide the information of a person not travaling with you to be contactad in the event of an emergency.
Name
Apartment #
City
State
Zip Code
Telephone E-Mail Address (Oprional)
I STOpl DO NOT SIGN APPLICATION UNTIL REQUESTED TODO SO BY PERSON ADMINISTERING OATH.
I declare under penalty of perjury that I am a United States citizen and have not, since acquiring United State citizenship, performed any of the
acts listed under "Acts or Conditions" on this application form (unless explanatory statement is attached). I solemnly swear (or affirm) that the
statements made on this application are true and correct and the photograph attached is a true likeness of me.
Applicant's or Father's Identification Information
Type of Document Issue Date
X 0 Driver's License Expiration Date
Applicant's Signature - age 14 and older 0 Passport
0 Military Identification Place of Issue
0 Other (Specify)
X Name
Mother's Legal Guardian's Signature (If identifying minor)
10 Number
Mother's Identification Information
X Type of Document
Father's Legal Guardian's Signature (If identifying minor) Issue Date
0 Driver's License Expiration Date
FOR ACCEPTANCE AGENT USE ONLY 0 Passport
0 Military Identification Place of Issue
Facility Identification Number 0 Other (Specify)
o Acceptance Agent; Facility Name & Location ~
o (Vice) Consul USA; Location 10 Number
o Passport Services Staff Agent (SEAL)
Subscribed & sworn to (affirmed) before me
Date (mm-dd-yyyy)
(Signature of person authorized to accept application)
For Issuing Office Use Only
Name as it appears on citizenship evidence:
o Birth Certificate o SR 0 CR 0 City , ,
File Date: issue Date: , ,
I ,
o Passport Issue Date: I ,
I ,
o Report of Birth 0240 0545 01350 I ,
Issue Date: I ,
I I
o Naturalization Cartlficate Issue Date: I I
Cert. #: I ,
I ,
o Citizenship Certificate Issue Date: Cert. #: I I
I I
o Other: I I
I APPLICATION APPROVAL I
I I
o Seen & Returned I
o Attached: I FEE EXEC. EF OTHER I
Page 2 of 2
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Applications and Forms
Page 1 of2
Friday August 19, 2005
Applications and Forms
If you already have Adobe Acrobat Reader and can print as specified, click on the left to select what
forms to print.
Print Passport Application Forms
It is now possible to print passport application forms in Portable Document Format (PDF). Adobe
PDF files require Acrobat Reader software from Adobe Systems Inc.
The forms you print must be clear and sharp. Applications that are blurred or illegible will not be
accepted. They must be printed in black print on white paper. The paper must be 8 1/2 inches by 11
inches, with no holes or perforations, at least medium (20 lb.) weight, and with a matte surface.
Thermal paper, dye-sublimation paper, special inkjet paper, and other shiny papers are not
acceptable.
Some printers will reduce the photograph area on the passport application to less than 2x2 inches.
Please make sure that the photograph area on the printed application form is 2x2 inches to ensure
that the photographs you submit (also 2x2 inches in size) can be correctly attached.
Please type or print legibly when completing all sections of the application.
PLEASE PRINT OUT AND SUBMIT ONLY ONE-SIDED PAGES OF THE APPLICATION.
Digitized Passports Photos
If you choose to submit digitized photos, they must meet the same requirements of all passport
photographs. In addition, digitized photographs are always produced on digital printers. Some
printers will produce a photograph in which the dots are seen.
Visible dots distort the image by making it look grainy. Acceptable photos have a continuous tone
image that looks very photo-like.
About Adobe PDF Formatted Files
The Adobe PDF format is modeled after the PostScript language and is device and resolution
independent. Passport application forms in the Adobe PDF format can be viewed, navigated and
printed from a workstation using Acrobat Reader software from Adobe Systems Inc. Adobe Systems,
Inc. allows the U.S. Department of State to offer this software free of charge to users downloading
passport applications. You must download the Adobe Acrobat Reader version that is suitable for
your system from the Adobe web site. Versions of Acrobat Reader are available for Windows,
Macintosh, and several other systems.
Get Adobe Acrobat Reader
Note: Selecting this link will send you out of this site to the Adobe home page.
If you have Adobe Acrobat Reader installed as a helper application or plug-in in your web browser,
you will only be allowed to view and print the document. If you wish to save the file for distribution
or later use, see your browser"s documentation for information on removing helper applications.
If you already have Adobe Acrobat Reader and can print as specified, find forms on the left or click
http://travel.state . gov /passport/forms/forms _ 84 7 .html
8/19/2005
Applications and Forms
here to select the forms to print from a list.
Most Passport Agencies now accept applications only by appointment. Click here for more
information.
Page 2 of2
This site is managed by the Bureau of Consular Affairs, U.S. Department of State.
External links to other Internet sites should not be construed as an endorsement ofthe views contained therein.
http://travel.state.gov/passport/forms/forms _ 84 7 .html
8/19/2005