Statement Of Non-Receipt Of A Passport
Statement Of Non-Receipt Of A Passport Form. This is a Official Federal Forms form and can be use in Passport US Department Of State.
Tags: Statement Of Non-Receipt Of A Passport, DS-86, Official Federal Forms US Department Of State, Passport
OMB Approval No.: 1405-0146 Expires: 03-31-2012 *Estimated Burden: 5 Minutes U.S. Department of State STATEMENT OF NON-RECEIPT OF A PASSPORT IMPORTANT NOTICE A U.S. citizen may not normally bear more than one valid or potentially valid passport book and one valid passport card at a time. The information you provide on the DS-86, Statement of Non-Receipt of a Passport, will be placed into our Consular Lost or Stolen Passport System. This system is designed to prevent the misuse of your U.S. passport. Anyone using the passport book or passport card reported on the DS-86, including yourself, may be detained upon entry into the United States. Should you locate the passport you reported as non-received 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. See page 2 of this form for additional information. Protect yourself against identity theft! Report the non-receipt of your passport book or passport card! Type or print legibly in blue or black ink in white areas only. Please select the document(s) which you are reporting. Passport Book Passport Card Last Name First Name Middle Name Date of Birth (mm-dd-yyyy) Home Telephone Number Work Telephone Number Please confirm your mailing address: Street Address Apartment Number City State ZIP Code Where was the previous application filed? (Check one only.) Clerk of Court Passport Agent Postal Employee City/State/Country (Vice) Consul USA Date (mm-dd-yyyy) Mailed (Renewals) I, the undersigned, certify that I filed an application for a passport of the type(s) specified above on the date and at the place shown above. I further attest that I have not received the passport book and/or passport card for which the application was filed. I declare under penalty of perjury that the statements made on this form are true and correct. I request that a passport be issued to me and certify that if the passport previously applied for is received, I will immediately return it to the U.S. Department of State. The address is provided on page 2 of this form. Signature Date (mm-dd-yyyy) PASSPORT OFFICE USE ONLY Was the passport mailed to the correct mailing address? Yes No Did the vendor (i.e. USPS, FedEx) confirm the delivery? Yes No Date Issued (mm-dd-yyyy) Previous U.S. Passport Book Number Place Issued Date Mailed (mm-dd-yyyy) Date Issued (mm-dd-yyyy) Previous U.S. Passport Card Number Place Issued DS-86 03-2009 Special Postage, If Used Date Mailed (mm-dd-yyyy) Special Postage, If Used Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com If the original passport is subsequently received after a replacement passport has been issued, send the original passport to the following address: U.S. Department of State Passport Services Consular Lost/Stolen Passport Section Attn: CLASP 1111 19th Street, NW, Suite 500 Washington, DC 20036 DO NOT USE THIS ADDRESS FOR ANY PASSPORT RELATED SERVICE OTHER THAN THAT DESCRIBED ABOVE. For More Information Call: 202-955-0430 or Visit our Website: www.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 and/or 18 U.S.C. 1542. Alteration or mutilation of a U.S. passport 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 submitted are subject to verification. PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS AUTHORITIES: Collection of the information solicited on this form is authorized by 22 U.S.C. 211a, et seq.; Executive Order 11295 (August 5, 1966); and Part 51, Title 22, Code of Federal Regulations (CFR), in particular 22 CFR 51.2(b). PURPOSE: The primary purpose for soliciting the information is to ensure that no person shall bear more than one valid or potentially valid U.S. passport book and one valid passport card at any one time, except as authorized by the U.S. Department of State, as well as to combat passport fraud and misuse. 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 administrative 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 (State-05) and Passport Records (State-26) published in the Federal Register. CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Failure to provide the information requested on this form may result in the refusal to issue a replacement passport. *Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this 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: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202. DS-86 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com