Fillable Printable Statement Regarding A Lost or Stolen U.S. Passport Book and/or Card - United States
Fillable Printable Statement Regarding A Lost or Stolen U.S. Passport Book and/or Card - United States
Statement Regarding A Lost or Stolen U.S. Passport Book and/or Card - United States
If you are applying for a new U.S. passport book and/or card, please submit this form with a new DS-11 U.S. passport application to any
designated acceptance facility , U.S. passport agency, U.S. embassy, or U.S. consulate abroad.
If you are not currently applying for a new U.S. passport book and/or card, send this form or a recovered lost or stolen U.S.
passport book and/or card to the following address:
U.S. Department of State
Passport Services
Consular Lost/Stolen Passport Unit
Attn: CLASP
600 19th Street, NW
Washington, DC 20522
To report a lost or stolen U.S. passport by telephone, call: 1-877-487-2778,
For more information, please visit our website: www. travel.state.gov
AUTHORITIES: We are authorized to collect this information by 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: We are requesting the information to ensure that no one has more than one U.S. passport book and one U.S. passport card at any one
time, except as authorized by the U.S. Department of State, and to combat passport fraud and misuse.
The collection of the Social Security number will be used to verify the identity of the person reporting the lost or stolen passport 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 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, result in processing delays or the denial of your passport applicat ion.
False statements made knowingly and willfully on this form, in U.S. passport applications, or in affidavits or other supporting documents submitted
therewith are punishable by fine and/or imprisonment under U.S. law, including the prov isions 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.
WARNING
PRIVACY ACT STATEMENT
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average ten minutes per response, including time 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 collection displays a currently valid OMB control number. If you hav e 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, D.C. 20520.
OR
The address should only be used to submit this form or other correspondence about lost/sto len passports. It should not be used for
general inquiries that are unrelated to lost/stolen passports.
HOW TO REPORT YOUR LOST OR STOLEN U.S. PASSPORT BOOK AND/OR PASSPORT CARD
U.S. Department of Stat e
STATEMENT RE GARDING A LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD
If you are submitting this form without also submitting a passport application, please provide a copy of a
government-issued photo identification, such as a driver's license or a state-issued identification card.
DS-64 08-2013
Page 1 of 2
ATTN: CLASP
U.S. Department of State
CA/PPT/S/L/LE
44132 Mercure Cir
P.O. Box 1227
Sterling, Virginia 20166-1227
Protect yourself against identity theft! Report a lost or stolen U.S. passport book or passport card!
Middle Name
First N a meLast Name
Date of Birth (mm-dd-yyyy)
E-mail Address
Work Telephone Number
Social Security Number
Has your name changed since the passport was issued? If yes, state the name in which the lost or stolen passport was issued.
Sex
List your lost or stolen U.S. Passport Book:
2. LOST OR STOLEN U.S. PASSPORT BOOK/CARD INFORMATION:
Place of Birth (City & State if in U.S. or City & Country)
List your lost or stolen U.S. Passport Card:
Female
Male
Home Telephone Number
()()
Current Address (Street, City, State, and ZIP Code)
Issue
Date (mm/dd/yyyy)
Number:
Issue
Date: (mm/dd/yyyy):
Number:
Answer all questions completely. If you do not know the
answer in detail, be as exact as possible.
2a. Explain how the document(s) were lost or stolen.
2b. Explain where the loss or theft occurred. Provide Address if known (City/State)
2c. On what date was your document(s) lost or stolen? (mm-dd-yyyy). If unknown, when was the last time y ou remember it in your possession?
I, the undersigned, declare under penalty of perjury all of the following: 1) That I have read and understood the warning on page one of this form;
2) The information furnished herein is correct and complete; 3) I have not given my U.S. passport book and/or passport card to another person or
disposed of it in an unauthorized manner; 4) I understand that the U.S. passport(s) I report as missing will be invalidated and can not be used; and 5)
if I subsequently find and recover it, I will immediately return it to Passport Services at the address on page one of this form or to the nearest U.S.
passport agency, U.S. embassy, or U.S. consulate abroad.
For a child under 16, this form must be signed by both parents or the child's legal guardian(s). In case of sole custody, include a copy of the
supporting document (court order) with this form.
STATEMENT REGARDING A LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD
U.S. Department of St at e
OM B CO NTR OL NO. 14 0 5-0014
OMB EXPIRATION DATE: 08/31/2015
ESTIM ATED BURDEN: 10 Mi nut e s
Page 2 of 2
1. IDENTIFYING INFORMATION: Type or print legibly in black ink in white areas only.
Please select the document (or documents) which y ou are reporting and their status.
U.S. Passport Card
Lost
Lost
StolenStolen
U.S. Passport Book
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 card at a time. It
therefore is necessary to submit a statement with an application for a new U.S. passport when a previously issued valid or potentially valid U.S.
passport book/card cannot be presented. Your statement must detail why the previous U.S. passport book/card cannot be presented. The
information you provide on the DS-64, "Statement Regarding a Lost or Stolen U.S. Passport Book and/or Card", will be placed into our Consular
Lost and Stolen Passport System. This system is designed to prevent the misuse of your lost or stolen U.S. passport book/card. Anyone using a
U.S. passport book/card reported on the DS-64, including yourself, may be detained upon entry into the United States. Should you locate the
reported lost or stolen U.S. passport at a later time, submit it for cancellation to the Consular Lost and Stolen Unit. It has been invalidated. You
may not use that U.S. passport for travel. See page one of this form for additional information.
DS-64 08-2013
2d. Have you had other U.S. passport book/card lost or stolen? How many times? What were the dates? Did y ou file a police report?
Please Print Legibly Using Black Ink Only
2e. Are you submitting this form in connection with an application for a new U.S. passport book and/or card?
YesNo
Yes
No
3. YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW
Legal Signature - age 16 or older or Parent/Guardian if under age 16
Date (mm/dd/yyyy)
Legal Signature - age 16 or older or Parent/Guardian if under age 16
Date(mm/dd/yyyy)
