Fillable Printable U.S. Passport Re-Application Form

U.S. Passport Re-Application Form

U.S. Department of State

U.S. PASSPORT RE-APPLICATION FORM

DS-5504

09-2005

Instruction Page 1 of 4

PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET

FOR YOUR RECORDS.

Date of Application:

CAREFULLY FOLLOW THE INSTRUCTIONS ON THE REVERSE OF THIS PAGE.

READ ALL WARNINGS, NOTICES AND STATEMENTS ON INSTRUCTION PAGES 3 AND 4.

INCOMPLETE OR UNACCEPTABLE APPLICATIONS WILL DELAY THE ISSUANCE OF YOUR PASSPORT.

CAN I USE THIS FORM?

Complete this checklist to determine your eligibility to use this form.

1. My most recent U.S. passport was issued less than one year ago.

2. I can submit my most recent U.S. passport.

3. I have had a change in my identifying information;

My identifying information was printed incorrectly;

-- OR --

My most recent U.S. passport was issued outside the United States and

limited in validity for one year or less, and/or issued abroad.

Yes

If you answered NO to any of the three statements above,

STOP - You cannot use this form!!!

You must apply on application form DS-11 or DS-82 depending on your circumstances. Please refer to those forms, visit

our website, or contact the National Passport Information Center for further information.

Yes

Please visit our website at www.travel.state.gov . In addition, contact the National Passport

Information Center (NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by e-mail

at [email protected]

. Customer Service Representatives are available Monday -Friday,

8AM-8PM EST (excluding Federal holidays). Automated information is available 24/7.

FOR INFORMATION, QUESTIONS, AND INQUIRES:

EVIDENCE TO SUPPORT A NAME CHANGE OR OTHER CHANGE IN DESCRIPTIVE DATA.

DS-5504

Instruction Page 2 of 4

What do I need to send with this application form?

YOUR MOST RECENT U.S. PASSPORT ISSUED LESS THAN ONE YEAR AGO.

If your name has changed you must submit a marriage certificate or court order showing the change of name. If you are unable to

document your name change in this manner, you must apply on the DS-11 Application form by making a personal appearance at (1) a

passport agency; (2) any Federal, State, or county court of record or any probate court accepting passport applications; or (3) a Post

Office which has been selected to accept passport applications.

All documents submitted for a name change or a data correction MUST bear the official seal of the issuing authority. Uncertified copies or

notarized documents cannot be accepted. All documents will be returned to you with your passport.

TWO RECENT COLOR PHOTOGRAPHS. Submit two color photographs of you alone, sufficiently recent to be a good

likeness of you (normally taken within 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 less than 1 inch and not more than 1 3/8 inches. The photographs must be color, clear,

with full front view of your face, and printed on thin paper with plain light (white or off-white) background. Photographs 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 purposes.

Photographs retouched so that your appearance is changed are unacceptable. Snapshots, most vending machine prints, and magazine or

full-length photographs are unacceptable. Digitized photos must meet the previously stated qualifications and will be accepted for use at the

discretion of Passport Services. (Visit our website for details.)

PLEASE NOTE: If you are re-applying because your U.S. passport was limited in validity due to a lack of citizenship evidence or identity,

please submit the necessary documents as specified by Passport Services. Please contact the National Passport Information Center for

detailed information and instructions.

How do I apply using this form?

COMPLETE, SIGN, AND DATE THIS FORM.

SEND THIS FORM WITH YOUR MOST RECENT U.S. PASSPORT, ANY REQUIRED ADDITIONAL EVIDENCE, AND

TWO RECENT, COLOR PHOTOGRAPHS TO:

Is there a fee associated with this form and

how will my new passport be mailed back to me?

There is no fee associated with the use of this form. Your re-issued U.S. passport and any documentary evidence submitted to Passport

Services will be return to you by priority mail.

If you desire Special Postal Service (overnight mail, special delivery, etc.) include appropriate postage fees or a pre-paid envelope.

NOTE: The Passport Center will not mail a passport to a private address outside the United States.

NOTE: If you choose to provide your e-mail address in item #11 on this application, Passport Services will only use that

information to contact you in the event there is a problem with your application or if you need to provide additional information to

us.

For faster processing, you may request Expedited Service. Expedited requests will be processed in three workdays from receipt at

the Passport Center. The fee for expedited service is $60. Enclose the $60 expedite fee in the form of a personal check or money order.

All fees should be payable to the "U.S. Department of State." Do not send cash. Expedited Service is available only in the United

States.

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. birth certificate or marriage certificate).

MAIL THIS FORM TO:

National Passport Processing

P.O. Box 13290

Philadelphia, PA 19101-3290

DELIVERY - OTHER THAN U.S. POSTAL SERVICE:

National Passport Processing

1617 Brett Road

ATTN: Department 13290

New Castle, DE 19720

DS-5504

Instruction Page 3 of 4

FEDERAL TAX LAW

Section 6039E of the Internal Revenue Code (26 U.S.C. 6039E) requires you to provide your Social Security Number

(SSN), if you have one, when you apply for a U.S. passport or renewal of a U.S. passport. If you have not been issued

a SSN, enter zeros in box #5 of this form. If you are residing abroad, you must also provide the name of the foreign

country in which you are residing. The U.S. Department of State must provide your SSN and foreign residence

information to the Department of Treasury. If you fail to provide the information, you are subject to a $500 penalty

enforced by the IRS. All questions on this matter should be directed to the nearest IRS office.

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.

NOTICE TO CUSTOMERS MAKING PAYMENT BY CHECK

You will not receive your original check back. We will destroy 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 be 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.

31 U.S.C. 7701 requires persons "doing business" with a federal agency to provide their security numbers to that

agency. Because the U.S. Department of State collects fee for the provision of passport services to you, you are

considered a person "doing business" with the Department. Passport service fees are established by law and

regulation (see 22 U.S.C. 214, 22 CFR 22.1, and 22 CFR 51.61-66) 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 you credit card, the U.S. Department of State

will take action to collect the delinquent fees from you under 22 CFR Part 34 and the Federal Claims Collection

Standards (see 31 CFR Parts 900-904). In accordance with the Debt Collection Improvement Act (Pub.L. 104-134), if

the fees remain unpaid after 180 days and no repayment arrangements have been made, the Department will refer the

debt to the Department of Treasury for collection. Debt collection procedures used by 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.

PAYMENT OF FEES

In addition, non-payment of passport fees will result in the invalidation of your passport. An invalidated passport cannot

be used for travel.

In addition to reporting your Social Security Number to Treasury and using it in connection with debt collection, the

Department checks Social Security Numbers against lists of persons ineligible or potentially ineligible to receive a U.S.

passport.

OTHER USES OF SOCIAL SECURITY NUMBERS

PAPERWORK REDUCTION STATEMENT

You are not required to provide the information requested on this form unless the form displays a currently valid OMB

number. We try to create forms and instructions that can be easily understood. Often this is difficult to do because our

citizenship laws are very complex. The estimated burden time for this information collection is 30 minutes, which

includes the time required to search existing data sources, gather the necessary data, complete and review this form,

and provide and submit the form and any additional information required. If you have comments concerning the

accuracy of this time estimate or suggestions for making this form simpler, we would be happy to hear from you. You

can write us at: U.S. Department of State (A/RPS/DIR), Washington, DC 20520.

IMPORTANT NOTICE TO APPLICANTS REGARDING LOST AND STOLEN PASSPORT

The Consular Lost or Stolen Passport System contains information provided by applicants regarding their lost or stolen

U.S. passports and is designed to prevent the misuse of lost or stolen U.S. passports. Anyone using the passport book

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

reported as lost or stolen, immediately report the book as found and submit it for cancellation. It has been invalidated.

You may not use that passport for travel.

PROTECT YOURSELF AGAINST IDENTITY THEFT - REPORT YOUR LOST OR STOLEN PASSPORT!

For more information or to report your lost or stolen passport by phone,

call NPIC or visit our website at www.travel.state.gov

DS-5504

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, 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.

PRIVACY ACT STATEMENT

AUTHORITIES: Collection of the information solicited on this form is authorized by Titles 8, 22, and 26 of the United

States Code, whether or not codified, including specifically 22 U.S.C. 211a et seq.; 26 U.S.C. 6039E, Section 236 of the

Admiral James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001;

Executive Order 11295 (August 5, 1966); and 22 CFR parts 50 and 51.

PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to

issuance of a U.S. passport.

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 requests for related services,

and for law enforcement and administration purposes. The information may be made available to foreign government

agencies to fulfill passport control and immigration duties. The information may also be provided to foreign government

agencies, international organizations and, in limited cases, private persons and organizations to investigate, prosecute,

or otherwise address potential violations of law or to further the Secretary's responsibility for the protection of U.S.

citizens and non-citizen nationals abroad. The information may be made available to private U.S. citizen 'wardens'

designated by the U.S. embassies and consulates. For a more detailed listing of the routine uses to which this

information may be put, see the Prefatory Statement of Routine Uses and the listing of routine users set forth in the

system descriptions for Overseas Citizen Services Records (State-05) and Passport Records (State-26) published in the

Federal Register.

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: With the exception of your Social Security Number

(see Federal Tax Law statement on Instruction Page 3), you are not legally required to provide the information

requested on this form. However, failure to do so may result in Passport Services' refusal to accept your application or

result in the denial of a U.S. passport.

ELECTRONIC PASSPORT STATEMENT

The U.S. Department of State will begin issuing a new type of passport containing an embedded electronic chip and

called an "Electronic Passport". The new passport will continue to be proof of the bearer's United States citizenship and

identity, and will look and function in the same way as a passport without a chip. The addition of an electronic chip in

the back cover will enable the new passport to carry a duplicate electronic copy of all information from the data page.

The new passport will be usable at all ports-of-entry, including those that do not yet have electronic chip readers.

Use of the electronic format will provide the traveler the additional security protections inherent in chip technology.

Moreover, when used at ports-of-entry equipped with electronic chip readers, the new passport will provide for faster

clearance through some of the port-of-entry processes.

Issuance of this new passport will be phased in during an 18-month period. It is expected that by mid-2006 nearly all

U.S. passports will be issued in this new format. The new passport will not require special handling or treatment, but

like previous versions should be protected from extreme bending and from immersion in water. The electronic chip must

be read using specially formatted readers, and is not susceptible to unauthorized reading.

The cover of the new passport will be printed with a special symbol representing the embedded chip. The symbol

will appear in port of entry areas where the electronic passport can be read.

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

You may use this application if you meet all of the provisions listed on Instruction Page 2, 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.

(See Federal Tax Law Notice

on Instruction Page 3)

(City and State OR City and Country)

( )

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

U.S. PASSPORT RE-APPLICATION FORM

U.S. Department of State

5 Yr. 10 Yr.

Issue

Date

End. Number

Exp.

RDPD

WARNING: False statements made knowingly and willfully in passport

applications, including affidavits or other supporting documents submitted

therewith, are punishable by fine and/or imprisonment under 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.

DS-5504

09-2005

Page 1 of 2

13. Permanent Address or Residence (If same as mailing address write "Same as Above")

Street / RFD # (DO NOT LIST P.O. BOX)

Apartment #

( )

14. Home Telephone (Include Area Code)

15. Business Telephone (Include Area Code)

( )

OMB APPROVAL NO. 1405-0160

EXPIRATION DATE: 08-31-2008

ESTIMATED BURDEN: 30 Minutes

(See Instruction Page 3)

2" x 2"

Submit two recent,

color photographs

2" x 2"

Name

Street / RFD #

Apartment #

City

State

ZIP Code

Telephone

E-mail Address

(Optional)

Relationship

18. Current U.S. Passport Information

Name - As printed in your most recent U.S. passport Date your most recent U.S. passport was issued (mm-dd-yyyy)

17. Travel Plans

Date of Trip (mm-dd-yyyy) Countries to be VisitedLength of Trip

Most Recent U.S. Passport Number (Passport must be submitted with this application) Place your most recent U.S. passport was issued

Male

Female

City State ZIP Code

1. Name of Applicant

Last

Suffix (Jr., Sr., III)

First

Street / RFD # OR Post Office Box

6. Height

Feet

Inches

12. Mailing Address11. E-Mail Address (Optional)

Apartment #

City State ZIP Code

8. Eye Color

9. Occupation 10. Employer

7. Hair Color

5. Social Security Number

In Care of (If applicable)Country (If outside the U.S.)

2. Date of Birth

3. Sex

4. Place of Birth

Middle

When completing this form, PRINT IN BLUE OR BLACK INK ONLY

(mm-dd-yyyy)

I declare under penalty of perjury that I am a United States citizen (or non-citizen national) and have not, since acquiring United State citizenship (or

U.S. nationality), performed any of the acts listed under "Acts or Conditions" on the reverse of this application form (unless explanatory statement is

attached). I declare under penalty of perjury that the statements made on this application are true and correct.

DS-5504

Page 2 of 2

APPLICATION APPROVAL

EF OTHER

Rewrite / Reissue

Other

Endorsement No.

- Adjudication Notes -

Evidence

Name Change

NAME OF APPLICANT (Last, First, Middle) Date of Birth (mm-dd-yyyy)

Please complete the following questions.

19. Has your name changed since your most recent passport was issued?

Limit To

FOR PASSPORT SERVICES USE ONLY

If yes, complete Section A below.

20. Was your identifying information printed incorrectly in your passport? If yes, complete Section B below.

21. Was your most recent passport limited for one year and/or issued abroad?

If yes, submit citizenship

evidence. Sign and date below.

SECTION A - NAME CHANGES (Submit original or certified documents only)

CHANGE NAME TO READ AS FOLLOWS:

Last

First / Middle

WAS YOUR NAME CHANGED BY MARRIAGE? If YES, give date of marriage.

What was your spouse's full name at their time of birth?

Last

First / Middle

WAS YOUR NAME CHANGED BY COURT ORDER? If YES, give date of court order.

What was the name of the court?

Where was the court located? (City, State)

SECTION B - PERSONAL INFORMATION CORRECTIONS

ATTENTION: COMPLETE ONLY THE SECTIONS THAT WERE PRINTED INCORRECTLY IN YOUR RECENTLY

ISSUED U.S. PASSPORT.

Name

Last

Suffix (Jr., Sr., III) First Middle

Date (mm-dd-yyyy) Signature of Applicant

OATH AND SIGNATURE

Date of Birth

(mm-dd-yyyy)

Date (mm-dd-yyyy)

FEE

YES

(City & State OR City & Country)

Place of Birth

Sex

Male

Female

(Submit original or certified documents only)