Fillable Printable Application for A U.S. Passport Name Change, Data Correction, And Limited Passport Book Replacement

Application for A U.S. Passport Name Change, Data Correction, And Limited Passport Book Replacement

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;

My identifying information in my most recent U.S. passport book and/or U.S.

passport card was printed incorrectly;

My most recent, full-fee U.S. passport book was limited in validity, and was issued

less than one year ago.

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.

APPLICATION FOR A U.S. PASSPORT

NAME CHANGE, DATA CORRECTION, AND LIM ITED PASSPORT BOOK REPLACEMENT

PLEASE DET ACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS

CAN I USE THIS FORM?

Complete this checklist to determine your eligibility to use this form

Yes

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 Nation al Passport Information Center for further information.

Yes

Date of Application:____________________________

INFORMATION, QUESTIONS, AND INQUIRIES

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.

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 [email protected]

. 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.

Instruction Page 1 of 4

FAILURE TO PROVIDE INFORMATION REQUESTED ON THI S 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.

DS-5504 11-2013

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.

If you answered NO to ALL of the four statements above,

STOP - You cannot use this form!

Yes

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 w ithin 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 le ss 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 purp oses. 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 a pp lic ation fo r m by

making a personal appe arance at (1) a passport agency; (2) U.S. Embassy or C onsulate, 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 spe cified by Passport Services. Passports limited in validity due to multiple losses c annot be extended.

Please contact the National Passport Information Center for detailed information and instructions.

HOW DO I APPLY USING THIS FORM?

MAIL FORM TO:

FOR ROUTINE SERVICE:

National Passport Processing Center

Post Office Box 90107

Philadelphia, PA 19190-0107

FOR EXPEDITED SERVICE (Additional Fee):

National Passport Processing Center

Post Office Box 90907

Philadelphia, PA 19190-0907

IS THERE A FEE ASSOCIATED WITH THIS FORM AND HOW WILL MY NEW

U.S. PASSPORT BOOK AND/OR PASSPORT CARD BE MAILED BACK TO ME?

There is no fee associated with the use of this form unless expedited service is requested (see below). Your re-issued passport book and/or passport card and

any documentary evidence submitted to Passport Services will be returned to you by priority or first class mail, unless overnight delivery is requested. You

may receive your newly issued document and your returned citizenship evidence in s eparate mailings. If you are app lying for both a U.S. passport book and

card you may receive three separate mailings; one with your returned citizenship evidence; one with your newly issued U.S. passport book, and one with

your newly printed U.S. passport card.

OVERNIGHT DELIVERY SERVICE

: If you desire overnight delivery service for the return of your passport, include the appropriate fee with your payment.

FASTER PROCESSING

: For an additional fee, you may r equest expedi ted service. Please include this fee in your pa yment, and sub mit the application to the

appropriate address. Please write "Expedite" on the outer envelope when mailing. ALSO, TO ENSURE MINIMAL PROCESSING TIME

for expedited

applications, Passport Services recommends using o vernight delivery when submitting the ap plication AND including the appropriate postage fee

for return overnight delivery for the completed passport. Expedited service is only available in the United States. Please visit travel.state.gov

for

updated information regarding fees and processing times.

Enclose the expedite and/or ov ernight deliver y fee in the form of a personal check or mone y order. MAKE CHECKS PAYABLE TO "U.S. DEPA RTMENT OF

STATE." THE FULL NAME AND DATE OF BIRTH OF THE APPLICANT MUST BE TYPED OR PRINTED ON THE FRONT OF THE CHECK. DO NOT

SEND CASH. Passport Services cannot be responsible for cash sent through the mail. By law, the fees are non-refundable. Please visit our website at

travel.state.gov

for detailed information regarding current fees.

NOTE REGARDING MAILING ADDRESSES: Passport Services will not mail a passport to a private address outside the United States. If you do not live at

the address listed in the "mailing address", then you must put the name of the person, and mark it as "In Care Of." If your mailing address changes prior to

receipt of your new U.S. passport, please contact the National Passport Information Center at 1-877-487-2778 or visit travel.state.gov

Instruction Page 2 of 4

1. Complete, sign, and date this form.

2. Send this form with your most recent U.S. passport book and/or passport card, any required additional evidence, and a recent color phot og raph .

DS-5504 11-2013

Because of the sensitivity of the enclosed documents, Passport Services r ecommends using trackable mailing ser vice when submitt ing your application.

Instruction Page 3 of 4

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 d estroy 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 b e 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.

NOTICE TO CUSTOMERS APPLYING OUTSIDE A STATE DEPARTMENT FACILITY

Passport service fees are established by law and regulation (see 22 U.S.C. 214, 22 C.F.R. 22.1, and 22 C.F.R. 51.50-56) 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 2 2 C.F.R. Part 34, and the Federal Claims Collection Standards (see 3 1 C.F.R. Parts 900-904). In accordance with

the Debt Collection Improvem ent Act (Pub.L. 104-13 4), if the fees remain un paid after 180 days and no repayment arrangemen ts have been made,

the U.S. Department of State will refer the debt to the U.S. Department of Treasury for collection. Debt collection procedures used by the U.S.

Department of 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 may result in the invalidation of your passport. An invalidated passport cannot be used for travel.

REMITTANCE OF FEES

IMPORTANT NOTICE TO APPLICANTS WHO HAVE LOST OR HAD A PREVIOUS U.S. PASSPORT BOOK

AND/OR PASSPORT CARD STOLEN

A United States citizen may not normally bear more tha n one valid or potentia lly valid U.S. passport book or more than one valid or potentially valid

U.S. passport card at a time. Therefore, when a valid or potentially valid U.S. passport book or U.S. passport card cannot be presented with a new

application, it is necessary to submit a Form DS-64, Statement Regarding a Lost or Stolen U.S. Passport. Your statement must detail why the

previous U.S. passport book or U.S. passport card cannot be presented.

The information you provide regarding your lost or stolen U.S. passport book or passport card 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 book or passport card. Anyone using the

passport book or passport card reported as lost or stolen may be detained upon entry into the United States. Should you locate the U.S. passport

book or passport card reported lost or stolen at a later time, report it as found, and submit it for cancellatio n. It has been invalidated

. You may not

use that passport book or passport card for travel.

PROTECT YOURSELF AGAINST IDENTITY THEFT!

REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD!

DS-5504 11-2013

NOTICE TO APPLICANTS FOR OFFICIAL, DIPLOMATIC, OR NO-FEE PASSPORTS

You may use this application if you meet the provisions listed, 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.

For more information or to report your lost or stolen U.S. passport book or passport card by phone, call NPIC or visit our website at travel.state.gov.

SPECIAL NOTICE TO U.S. PASSPORT CARD APPLICANTS ONLY

The maximum number of letters provided for your given name (first and middle) on the U.S. Passport Card is 24 characters. The 24 characters may be

shortened due to printing restrictions. If both your given names are more than 24 characters, you must shorten the given name you list on item 1 of this form.

Instruction Page 4 of 4

ACTS OR CONDITIONS

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/nationality, 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.

Furthermore, I have not been con victed of a federal or state drug offense or convicted for “sex tourism ” crimes statute, and I am not the subject of

an outstanding federal, state, or local warrant of arrest for a felony; a criminal court order forbidding my departure from the United States; a

subpoena received from the United States in a matter involving federal prosecution for, or grand jury investigation of, a felony.

PRIVACY ACT STATEMENT

AUTHOR ITIES: We are au thorized to collect this inform ation by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; Executive Order 11295 (Au gust 5, 1966);

and 22 C.F.R. parts 50 and 51.

PURPOSE: We are requesting this information in order to determine your entitlement to receive the passport service for which you are applying.

The collection of the Social Security number will be used for identity/entitlement verification only and no other purpose unless authorized by law.

ROUTIN E USES: This information may be disclosed to another d omestic government ag ency, a private contractor, a foreign government agency,

or to a private person or private employer in accordance with certain approved rou tine 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 application.

ELECTRONIC PASSPORT STATEMENT

The U.S. Department of State now issues an "Electronic Passport" book, which contains an embedded electronic chip. The electronic passport

book continues to be proof of the bearer's United States citizenship/nationality and identity, and looks a nd functions in the same way as a passport

without a chip. The addition of an electronic chip in the back co ver enables the passport book to carry a duplicate electronic copy of all information

from the data page. The electronic passport book is usable at all ports-of-entry, including those that do not yet have electronic chip readers.

Use of the electronic format provides the traveler the additional security protections inherent in chip technology. Moreover, when used at

ports-of-entry equipped with electronic chip readers, the electronic passport book provides for faster clearance through some of the port-of-entry

processes.

The electronic passport book does not require special handling or treatment, but like previous versions should be protected from extreme heat,

bending, and from immersion in water. The electronic chip must be read using specially formatted readers, which protects the data on the chip

from unauthorized reading.

The cover of the electronic passport book is printed with a special symbol representing the embedded chip. The symbol will appear in

port-of-entry areas where the electronic passport book can be read.

DS-5504 11-2013

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burd en for this collection of information is estimated to average 40 minutes p er response, including the tim e required for searching

existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection. You

do not have to supply this information u nless this colle ction di splays a currently valid OMB control number. If you have comme nts 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, D.C. 20520.

I declare under penalty of perjury all of the following: 1) I am a citizen or non-citizen national of the United States and have not, since acquiring U.S. citizenship or nationality,

performed any of the acts listed under "Acts or Conditions" on page four of the instructions of this application (unless explanatory statement is attached); 2) the statements made on

the application are true and correct; 3) I have not knowingly and willfully made false statements or included false documents in support of this application; 4) the photograph

submitted with this application is a genuine, current photograph of me; and 5) I have read and understood the warning on page one of the instructions to the application form.

Applicant's Legal Signature - age 16 and older

FOR ISSUING OFFICE ONLY

Name Change

Other:

Attached:

Postage Other

APPLICATION FOR A U.S. PASSPORT

OMB CONTROL NO. 1405-0160

OMB EXPIRATION DATE : 01-31-20 17

ESTIMATED BURDEN: 40 MIN

STAPLE

2" x 2"

STAPLE

STAPLESTAPLE

YOU MUST SIG N AND DAT E THE APPLI CAT ION IN THE DESIGNATED AREA BELOW

Page 1 of 2

DS-5504 11-2013

* DS 5504 C 11 2013 1 *

Please Print Legibly Using Black Ink Only

10. U.S. Passport Book and/or Passport Card Information

Your name as printed on your most recent U.S. passport book and/or passport card

Most recent U.S. passport book number

Most recent U.S. passport card number

Book Issue Date (mm/dd/yyyy)

Card Issue Date (mm/dd/yyyy)

End. #

O DP DOTS Code

Exp.

CONTINUE TO PAGE 2

Date

Mother/F ath er/Pa rent/ L ega l Guardi an's Si gnat ure (i f iden ti fying m inor )

BC Nat/Citz Cert Report of Birth Prev PPT MC Adoption C/O NC C/O PIERS Other

Filed/Issued/Place: Doc #:

From:

To:

Attention: Read WARNING on page 1 of instructions

Please select the document(s) for which you are applying:

U.S. Passport Book

U.S. Passport Card

28 Page Book (Standard)

The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions.

Note: The 52 page option is for those who frequently travel abroad during the passport validity period and is recommended

for applicants who have previously required the addition of visa pages.

A. B.

City Zip Code

Country, if outside the United States

State

9. List a ll othe r na mes you have us ed. (Exam ples: Birth Nam e, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed.)

Address Line 2: Clearly l abe l Apartment, Company, Suite, Unit, Building, Floor, In Care Of or Attention if applicable. (e.g., In Care Of - Jane Doe, Apt # 100)

4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.)

First

Middle

3. Sex

6. Email Address (e.g., my_email@domain.com)

7. Primary Contact Phone Number

5. Social Security Number

2. Da te of Birth (mm/dd/yyyy)

1. Name Last

8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.

Replacement Correction: LName FName MName DOB Sex POB Other

NAME CHANGE, DATA CORRECTION, AND LIMITED PASSPORT BOOK REPLA CEMENT

Both

52 Page Book (Non-Standard)

Attach a color photograph

taken within the last six months

Please complete the following questions regarding your current passport book and/or passport card

16. Additional Contact Phone Numbers

11. Height 12. Hair Color 13. Eye Color

14. Occupation (if age 16 or older)

15. Employer or School (if applicable)

17. Permanent Address: If P.O. Box is listed under Mailing Address or

if residence is different from M ailing Address.

Apartment/Unit

City

State

18. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency.

Name Apartment/Unit

City Relationship

19. Travel Plans

Departure Date (mm/dd/yyyy)

Countries to be visited

Zip Code

Address: Street/RFD # or P.O. Box

State

Zip Code Phone Number

Return Date (mm/dd/yyyy)

Street/RFD # or URB (No P.O. Box)

Date of Birth (mm/dd/yyyy) Name of Applicant (Last, First & Middle)

Home Cell

Work

DS-5504 11-2013 Page 2 of 2

Has your name changed by marriage or court

order since your U.S. passport book or

passport card was issued?

If yes, please complete this section with your

curr e nt inform ation.

Note: To complete a name change your submitted U.S. passport book and/or passport card must be less than one year old.

Please submit evidence documenting your name change (such as a certified marriage certificate or court order) and your current U.S. passport book

and/or passport card, along with this completed form to the address listed on page 2 of the instructions.

Current Name Last

First Middle

Was your identifying information printed

incorrectly in your U.S. passport book or passport

card?

Name Last

If yes, please complete the information as it should

appear, and check only the box(s) next to the

field(s) to be corrected.

First

Middle

Date of Birt h (mm/dd/yyyy) Sex

Place of Birth (State or Country)

Please submit evidence documenting your correct identifying information (such as a certified marriage certificate or birth certificat e) and your

current U.S. passport book and/or passport card, along with this completed form to the address listed on page 2 of the instructions.

Was your most recent U.S. passport limited for

one year or less?

Yes No

If yes, please submit evidence of your United States

citizenship (such as a government-issued birth

certificate) and/or evidence of your identity (such as a

driver's license or a state issued identification (ID)

card).

Note: To complete a limited U.S. passport book replacement, your submitted U.S.

passport book must not be expired. Passport books limited in validity because of

multiple losses, damages, or mutilations cannot be extended.

Please be sure to enclose your U.S. passport book along with this application to the

address listed on page 2 of the instructions.

Yes No

Cell

Work

Home

* DS 5504 C 11 2013 2 *