Fillable Printable Form DS-86
Fillable Printable Form DS-86
Form DS-86
I, the undersigned, certify that I have not received the U.S. passport book and/or U.S. passport card for which I applied. I declare under penalty of
perjury that the statements made on this form are true and correct. I request that a new U.S. passport book and/or U.S. passport card be issued to me,
and certify that if I receive the U.S. passport book and/or U.S. passport card for which I previously applied, I will immediately contact the National
Passport Information Center at 1-877-487-2778 (TDD: 1-888-874-7793) and return the recovered passport to the U.S. Department of State.
Special Postage, if used
Date Mailed (mm-dd-yyyy)
Place Issued
Date Issued (mm-dd-yyyy)
Previous U.S. Passport Card Number
Previous U.S. Passport Book Number
Place Issued Date Mailed (mm-dd-yyyy)
Special Postage, if used
Mailing Address
Secondary Telephone Number
Primary Telephone Number
Date of Birth (mm-dd-yyyy)
Middle Name
First Name
Last Name
Social Security Number
IMPORTANT NOTICE
A U.S. citizen may not normally bear more than one valid or potentially valid U.S. passport book and one valid U.S.
passport c ard at a time. Yo u have 90 days from the date that you r passport docum ent(s) was issued t o report that yo u
have not yet received it in the mail. If you do not report the non-receipt of your U.S. passport document(s) within
90 days of the issue date, you will be required to reapply and submit the full passport fee(s). To check the status
of your U.S. passport application, please visit travel.state.gov
or contact our National Passport Information Center
(NPIC) 1-8 77 - 48 7-2778 (TDD: 1- 88 8-874-7793) .
DS-86
03-2014
Page 1 of 2
PASSPORT OFFICE USE ONLY
Mother/Father/Parent/Legal Guardian's Signature (if applicant is under age 16)
Applicant's Signature (age 16 and older)
U.S. Department of State
OMB Approval No. 1405-014 6
Expiration Date: 09-30-2017
Estimated Burden: 15 Minutes
STATEMENT OF NON-RECEIPT OF A U.S. PASSPORT
Was the passport mailed to the correct mailing address?
Yes No
Was delivery confirmed?
No
Yes
UPS
Fed Ex
Vendor:
DHLUSPS
Tracking Number:
Apartment /Unit
Street Address
City ZIP Code
Please select the document(s) which you are reporting.
U.S. Passport Book
Protect yourself against identity theft! Report the non-receipt of your U.S. passport book or U.S. passport card!
Type or print legibly in black ink in the white areas only.
Date Issued (mm-dd-yyyy)
The information that you provide on the DS-86, Statement of Non-Receipt of a U.S. Passport, will be entered into the
Consular Lost or Stolen Passport System. Anyone using the U.S. passport book or U.S. passport card reported on the
DS-86, including yourself, may be detained. Should you receive the document you reported as not received at a later
time, repo rt it as fo und an d subm it it for cance llation . It has been invalidated. You may not use it for travel
. See page
two of this for m fo r a dd it ion al info r m ation.
This application must be accompanied by a clear photocopy of the
front and back of an identification document containing your photograph.
U.S. Passport Card
State
Travel Date (mm-dd-yyyy)
Date of Birth (mm-dd-yyyy)
Date (mm-dd-yyyy)
HOW TO USE THIS FORM
PAPERWORK REDUCTION ACT STATEMENT
PRIVACY ACT STATEMENT
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, 18 U.S.C. 1542, and/or 18 U.S.C. 1621. Alteration or mutilation of a
U.S. 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 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 are subject to verification.
DS-86 Page 2 of 2
To determine how and when to use this form, please call the National Passport
Information Center (NPIC) at 1-877-487-2778 (TDD: 1-888-874-7793).
AUTHORITIES: The information on this form is requested under the authority of 22 U.S.C. 211a et
seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E; Executive Order 11295 (August 5, 1966); and 22 C.F.R.
parts 50 and 51.
PURPOSE: The information collected on this form will be used to determine whether to issue you a
replacement U.S. passport. The collection of the Social Security number will be used for
identity/entitlement to passport verification only and no other purpose unless authorized by law.
ROUTINE USES: This information may be disclosed to another domestic government agency, a
private contractor, a foreign government agency, or to a private person or private employer in
accordance with certain approved routine 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 passport
application.
Public reporting burden for this collection of information is estimated to average 15 minutes per
response, including time required for searching existing data sources, gathering the necessary
data, providing the information and/or documentation required, and reviewing the final collection.
You do not have to supply this information unless the 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 U.S. Department of State, Bureau of
Consular Affairs, Passport Services, Office of Program Management and Operational Support,
2201 C Street, NW, Washington, DC 20520.
For more information, please visit our website at travel.state.gov.
This form must be mailed to the passport agency that originally processed your
application. To obtain the address of that agency, please call NPIC at the number above.
