APPLICATION FOR A U.S. PASSPORT PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS I applied: Place: Date: 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. 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 U.S. PASSPORT BOOK OR U.S. PASSPORT CARD. THE PASSPORT CARD IS A U.S. PASSPORT ISSUED IN CARD FORMAT. LIKE THE TRADITIONAL U.S. PASSPORT BOOK, IT REFLECTS THE BEARER'S ORIGIN, IDENTITY, AND NATIONALITY AND IS SUBJECT TO EXISTING PASSPORT LAWS AND REGULATIONS. UNLIKE THE U.S. PASSPORT BOOK, THE U.S. 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. IMPORTANT NOTICE TO APPLICANTS WHO HAVE HAD A PREVIOUS U.S. PASSPORT BOOK AND/OR PASSPORT CARD LOST OR STOLEN - You are required to submit a Form DS-64, Statement Regarding a Lost or Stolen U.S. Passport, when your valid or potentially valid U.S. passport book and/or passport card cannot be submitted with this application. IN MY POSSESSION - If your most recent U.S.passport book and/or passport card was issued less than 15 years ago, and you were over the age of 16 at the time of issuance, you may be eligible to use Form DS-82 to renew your passport by mail. If your most recent passport is valid and needs additional pages, you can submit your passport, form DS-4085, and the current fee. SPECIAL REQUIREMENTS FOR CHILDREN AS DIRECTED BY PUBLIC LAW 106-113 AND 22 CFR 51.28: To submit an application for a child under age 16 both parents or the child's legal guardian(s) must appear and present the following: - Evidence of the child's U.S. citizenship; - Evidence of the child's relationship to parents/guardian(s); AND - Parental/guardian government-issued identification. IF ONLY ONE PARENT APPEARS, YOU MUST ALSO SUBMIT ONE OF THE FOLLOWING: - Second parent's notarized written statement or DS-3053 (including the child's full name and date of birth) consenting to the passport issuance for the child. The notarized statement cannot be more than three months old and must be signed and notarized on the same day, and must come with a photocopy of the front and back side of the second parent's government-issued photo identification; OR - Second parent's death certificate if second parent is deceased; OR - Primary evidence of sole authority to apply; OR - A written statement or DS-5525 (made under penalty of perjury) explaining in detail the second parent's unavailability. AS DIRECTED BY REGULATION 22 C.F.R. 51.21 AND 51.28: - Each minor child applying for a U.S. passport book and/or passport card must appear in person. 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. WHAT TO SUBMIT WITH THIS FORM: 1. 2. 3. 4. PROOF OF U.S. CITIZENSHIP (Evidence of U.S. citizenship that is not damaged, altered, or forged will be returned to you.) PROOF OF IDENTITY (You must present your original identification AND submit a photocopy of the front and back side with your passport application.) RECENT COLOR PHOTOGRAPH (Photograph must meet passport requirements ­ full front view of the face and 2x2 inches in size.) FEES (Please visit our website at travel.state.gov for current fees.) See page 2 of the instructions for detailed information on the completion and submission of this 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 or state 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; an agent at a passport agency (by appointment only); or a U.S. consular official at a U.S. Embassy or Consulate, if abroad. To find your nearest acceptance facility, visit travel.state.gov or contact the National Passport Information Center at 1-877-487-2778. 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 herein 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. DS-11 09-2013 American LegalNet, Inc. www.FormsWorkFlow.com Instruction Page 1 of 4 1. PROOF OF U.S. CITIZENSHIP APPLICANTS BORN IN THE UNITED STATES: Submit a previous U.S. passport or certified birth certificate. Passports that are limited in validity will need to be supplemented by other evidence. A birth certificate must include your full name, date and place of birth, sex, date the birth record was filed, the seal or other certification of the official custodian of such records (state, county, or city/town office), and the full names of your parent(s). - If the birth certificate was filed more than 1 year after the birth: It must be supported by evidence described in the next paragraph. - If no birth record exists: Submit a registrar's notice to that effect. Also, submit a combination of the evidence listed below, which should include your given name and surname, date and/or place of birth, and the seal or other certification of the office (if customary), and the signature of the issuing official. A hospital birth record; An early baptismal or circumcision certificate; Early census, school, medical, or family Bible records; Insurance files or published birth announcements (such as a newspaper article); and Notarized affidavits (or DS-10,