APPLICATION FOR A U.S. PASSPORT NAME CHANGE, DATA CORRECTION, AND LIMITED PASSPORT BOOK REPLACEMENT PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS Date of Application:____________________________ CAN I USE THIS FORM? Complete this checklist to determine your eligibility to use this form I have changed my name since my most recent U.S. passport book and/or U.S. passport card was issued less than one year ago; OR My identifying information in my most recent U.S. passport book and/or U.S. passport card was printed incorrectly; OR My most recent, full-fee U.S. passport book was limited in validity, and was issued less than one year ago. OR My most recent, full-fee U.S. passport book was limited in validity due to a lost naturalization certificate or due to gender transition, and was issued less than two years ago. Yes No Yes No Yes No Yes No If you answered NO to ALL of the four statements above, STOP - You cannot use this form! You must apply on application form DS-11 or DS-82 depending on your circumstances. Please refer to those forms, visit travel.state.gov, or contact the National Passport Information Center for further information. U.S. PASSPORTS, EITHER IN BOOK OR CARD FORMAT, ARE ISSUED ONLY TO U.S. CITIZENS OR NON-CITIZEN NATIONALS. EACH PERSON MUST OBTAIN HIS OR HER OWN PASSPORT BOOK OR PASSPORT CARD. THE PASSPORT CARD IS A U.S. PASSPORT ISSUED IN CARD FORMAT. LIKE THE TRADITIONAL PASSPORT BOOK, IT REFLECTS THE BEARER'S ORIGIN, IDENTITY, AND NATIONALITY AND IS SUBJECT TO EXISTING PASSPORT LAWS AND REGULATIONS. UNLIKE THE PASSPORT BOOK, THE PASSPORT CARD IS VALID ONLY FOR ENTRY TO THE UNITED STATES AT LAND BORDER CROSSINGS AND SEA PORTS OF ENTRY WHEN TRAVELING FROM CANADA, MEXICO, THE CARIBBEAN, AND BERMUDA. THE U.S. PASSPORT CARD IS NOT VALID FOR INTERNATIONAL AIR TRAVEL. INFORMATION, QUESTIONS, AND INQUIRIES Please visit our website at travel.state.gov. In addition, you may contact the National Passport Information Center (NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by email at NPIC@state.gov. Customer Service Representatives are available Monday-Friday 8:00a.m.-10:00p.m. Eastern Time (excluding federal holidays.) Automated information is available 24 hours a day, 7 days a week. FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM, INCLUDING YOUR SOCIAL SECURITY NUMBER, MAY RESULT IN SIGNIFICANT PROCESSING DELAYS AND/OR THE DENIAL OF YOUR APPLICATION. NOTICE TO APPLICANTS RESIDING ABROAD United States citizens residing abroad CANNOT submit this form to the domestic address listed on the Instruction Page 2. Such applicants should contact the nearest U.S. Embassy or Consulate for procedures to be followed when applying overseas. WARNING: False statements made knowingly and willfully in passport applications, including affidavits or other documents submitted to support this application, are punishable by fine and/or imprisonment under U.S. law, including 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 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 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. See page 2 of the instructions for detailed information on the completion and submission of this form. If you choose to provide your email address in Item #6 on this application, Passport Services may use that information to contact you in the event there is a problem with your application or if additional information is required. DS-5504 11-2013 Instruction Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com WHAT DO I SEND WITH THIS APPLICATION FORM? 1. Your most recent U.S. passport book and/or passport card. 2. A recent color photograph. Submit a color photograph of you alone, sufficiently recent to be a good likeness of you (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 photograph must be color, clear, with a full front view of your face, and printed on thin paper with plain light (white or off-white) background. The photograph 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. Headphones, "bluetooth", or similar devices must not be worn in the passport photograph. Any photograph retouched so that your appearance is changed is unacceptable. A snapshot, most vending machine prints, and magazine or full-length photographs are unacceptable. A digital photo must meet the previously stated qualifications, and will be accepted for use at the discretion of Passport Services. (Visit our website at travel.state.gov for details and information.) 3. Evidence to support a name change or other change in descriptive data. If your name has changed, the name change document you submit must be a certified copy of your marriage certificate or a certified copy of a court order showing a seal and officiate/judge signature. If you are unable to document your name change in this manner, you must apply on the DS-11 application form by making a personal appearance at (1) a passport agency; (2) U.S. Embassy or Consulate, if abroad; (3) any federal or state court of record or any probate court accepting passport applications; (4) a designated municipal or county official; or (5) a post office, which has been selected to accept passport applications. If there is a change or an error in the descriptive data in your recently issued passport, you must submit the appropriate evidence showing the correct information (e.g. certified birth certificate or certified marriage certificate as described above). All documentary evidence that is not damaged, altered, or forged will be returned to you. PLEASE NOTE: If you are re-applying, because your U.S. passport book was limited in validity due to a lack of citizenship evidence or identity, please submit the necessary document as specified by Passport Services. Passports limited in validity due to multiple los