Fillable Printable LOST OR STOLEN PASSPORT NOTIFICATION (Official Passport Office use only)

LOST OR STOLEN PASSPORT NOTIFICATION (Official Passport Office use only)

PLEASE WRITE IN BLOCK CAPITALS IN BLACK INK OR BALL POINT PEN

LOST OR STOLEN

PASSPORT NOTIFICATION

1. DETAILS OF THE LOST/STOLEN PASSPORT

TITLE ............................... SURNAME ON PASSPORT ......................................................................................

FORENAME(S) ON PASSPORT ............................................................................................................................

DATE OF BIRTH __ __/__ __/__ __ __ __

TOWN OF BIRTH ............................................ COUNTRY OF BIRTH ....................................................

PASSPORT NUMBER PLACE OF ISSUE DATE OF ISSUE

_____________________ ______________________ __ __/__ __/__ __ __ __

PLEASE TICK THE APPROPRIATE BOX: LOST

❏

STOLEN

❏

OTHER

❏

IF OTHER PLEASE SUPPLY DETAILS

..................................................................................................................................................................................

2. CURRENT DETAILS - ONLY COMPLETE IF DIFFERENT TO SECTION 1

CURRENT TITLE ............................... CURRENT SURNAME ........................................................................

CURRENT FORENAME(S) ..................................................................................................................................

3. DETAILS OF WHERE AND WHEN LOST/STOLEN PASSPORT WAS LAST SEEN

DATE OF LOSS/THEFT __ __/__ __/__ __ __ __

PLACE OF LOSS/THEFT (E.G. NAME OF AIRPORT OR NAME AND TOWN OF HOTEL)

..................................................................................................................................................................................

COUNTRY OF LOSS/THEFT

..................................................................................................................................................................................

POSTCODE OF LOSS/THEFT (IF KNOWN)

..................................................................................................................................................................................

CIRCUMSTANCES OF LOSS/THEFT

..................................................................................................................................................................................

Official Passport Office use only

Lost or Stolen reference Application Number

LS01

PLEASE WRITE IN BLOCK CAPITALS IN BLACK INK OR BALL POINT PEN

4. POLICE REPORT

HAS THE THEFT BEEN REPORTED TO THE POLICE? YES

❏

DATE REPORTED TO POLICE __ __/__ __/__ __ __ __

POLICE STATION ..................................................................................................................................................

POLICE REPORT NUMBER ................................................................................................................................

5. NAME OF PERSON REPORTING THE LOSS/THEFT

Complete this Section only if you ar

e not the passport Holder.

A person with parental responsibility must complete section 5 if the passport holder is aged under 16 (this form should not be

used where there is a parental dispute over the possession of a child’s passport). If you are completing this form on behalf of

an adult passport holder please enclose a covering letter explaining clearly why the passport holder cannot complete this form

him/herself.

TITLE ............................. SURNAME ....................................................................................................................

FORENAME(S) ......................................................................................................................................................

RELATIONSHIP TO PASSPORT HOLDER ..........................................................................................................

6. CONTACT DETAILS OF PERSON REPORTING THE LOSS/THEFT

Complete this section only if this form is not Accompanying an application for a replacement passport.

PRESENT ADDRESS ..............................................................................................................................................

..................................................................................................................................................................................

.............................................................................................................. POSTCODE ............................................

DAYTIME TELEPHONE NUMBER ....................................................................................................................

MOBILE TELEPHONE NUMBER ........................................................................................................................

E-MAIL ADDRESS ..................................................................................................................................................

7. DECLARATION

Note all unsigned forms will be returned.

I understand that completing and returning this form will result in the related passport being cancelled, that it may never be

used again and, if subsequently found, it should be returned to the Passport Office immediately. I also understand that I will

need to make a separate application on a passport application form if I wish to replace the passport declared lost or stolen.

The information on this form is true to the best of my knowledge and belief and I understand that I shall be liable to

prosecution and could face a prison sentence if I include anything that I know to be false or do not believe to be true.

The Passport Offices of the Channel Islands and the Isle of Man hold and use data in accordance with the relevant Data

Protection legislation for each jurisdiction. The information provided on this form may be shared with public and private sector

authorities in the islands, the United Kingdom and other countries who can assist in locating and recovering the passport.

PRINT NAME ........................................................................................................................................................

SIGNATURE ..................................................................................................... DATE __ __/__ __/__ __ __ __

OFFICIAL PASSPORT OFFICE USE ONLY

SOURCE AUTHORITY ..........................................................................................................................................

LSR SUBMISSION POST ......................................................................................................................................

SOURCE AUTHORITY SOURCE SYSTEM REFERENCE ................................................................................

SOURCE CONTACT DETAILS ............................................................................................................................