Fillable Printable Statement Regarding Lost or Stolen Passport

Statement Regarding Lost or Stolen Passport

U.S. Department of State

STATEMENT REGARDING LOST OR STOLEN PASSPORT

INSTRUCTIONS

A United States citizen may bear only one valid or potentially valid passport at a time, except as otherwise authorized by the U.S. Department of State. It

therefore is necessary to submit a statement with an application for a new passport when a previous valid or potentially valid passport cannot be presented. This

statement must be set forth in detail why the previous passport cannot be presented.

IDENTIFYING INFORMATION TYPE OR PRINT IN INK IN WHITE AREAS ONLY

PASSPORT

ISSUE DATE

(mm-dd-yyyy)

PLACE OF

NAME

FIRST NAME MIDDLE NAME

LAST

SEX

Male Female

PLACE OF BIRTH

City, State or Province, Country

DATE OF BIRTH

(mm-dd-yyyy)

ADDRESS (Street, City, State, ZIP Code)

(For Official Use Only)

DOCUMENT CODE

LOST/STOLEN PASSPORT INFORMATION

HOW WAS PASSPORT LOST OR STOLEN?

WHEN WAS LOSS DISCOVERED?

WHERE DID LOSS TAKE PLACE?

IF STOLEN, WERE POLICE AUTHORITIES NOTIFIED?

Yes No

IF YES, STATE

WHERE AND WHEN

WHAT EFFORTS HAVE YOU MADE TO RECOVER THE PASSPORT?

HAVE YOU HAD PREVIOUS PASSPORTS LOST OR STOLEN?

Yes No

IF YES, GIVE DATE (mm-dd-yyyy) AND PARTICULARS,

INCLUDING NUMBER OF PASSPORTS LOST OR STOLEN.

WARNING

False statements made knowingly and willfully in passport applications or in affidavits or other documents submitted with

passport applications are punishable by fine and/or imprisonment (18 U.S.C. 1001 and 1542). Passports reported lost or stolen

are entered into lookout systems and will be considered invalid at ports of entry. Use of a lost or stolen passport could result in

prosecution for the misuse of a United States passport (18 U.S.C 1544).

CERTIFICATION I, the undersigned, certify that the information furnished herein is correct and complete to the

best of my knowledge and belief, and that I have not given my passport to another person or disposed of it in an

unauthorized manner. If I subsequently find or recover it, I will immediately return it to Passport Services

(Attention: Correspondence Branch), U.S. Department of State, Washington, D.C. 20522-1705 or to the nearest

Passport Agency.

Date mm-dd-yyyy)

Signature

In accordance with 5 CFR 1320 5(b), persons are not required to respond to the collection

of this information unless this form displays a currently valid OMB control number.

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12-2002

OMB No. 1405-0014 Expires 12/31/2005 Estimated Burden 5 Minutes (See Page 2)

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PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS

AUTHORITIES: The information solicited on this form is requested pursuant to provisions in Titles 8, 18, and 22 of the United States Code,

whether or not codified, including specifically 22 U.S.C. 211a, 212, and 213, and all regulations issued pursuant to Executive Order 11295

(August 5, 1966), including Part 51, Title 22, Code of Federal Regulations (CFR). Also, as specifically noted, pursuant to 26 U.S.C. 6039E.

PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to issuance of a U.S.

passport. The information may also be used in connection with issuing other travel documents or evidence of citizenship, and in furtherance of

the Secretary's responsibility for the protection of U.S. nationals abroad.

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 for law enforcement and administrative purposes. It may also be disclosed

pursuant to court order. The information may be made available to foreign government agencies to fulfill passport control and immigration

duties or to investigate or prosecute violations of law. The information may also be made available to private U.S. citizen 'wardens'

designated by U.S. embassies and consulates.

Failure to provide the information requested on this form may also result in the denial of a United States passport, related document, or

service to the individual seeking such passport, document, or service.

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 data, providing the information required, and reviewing the final collection. You do not have to

provide the information unless this collection displays a currently valid OMB number. Send comments on the accuracy of this estimate of the

burden and recommendations for reducing it to: U.S. Department of State (A/RPS/DIR) Washington, DC 20520.

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