Form DS-5504 "Application for a U.S. Passport, Corrections, Name Change Within 1 Year of Passport Issuance, and Limited Passport Holders"

What Is Form DS-5504?

This is a legal form that was released by the U.S. Department of State on June 1, 2016 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2016;
  • The latest available edition released by the U.S. Department of State;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DS-5504 by clicking the link below or browse more documents and templates provided by the U.S. Department of State.

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Download Form DS-5504 "Application for a U.S. Passport, Corrections, Name Change Within 1 Year of Passport Issuance, and Limited Passport Holders"

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APPLICATION FOR A U.S. PASSPORT
CORRECTIONS, NAME CHANGE WITHIN 1 YEAR OF PASSPORT ISSUANCE, AND LIMITED PASSPORT HOLDERS
PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS
Mailing Date of Application:____________________________
CAN I USE THIS FORM?
Complete this checklist to determine your eligibility to use this form
I have changed my name less than one year since my most recent U.S. passport
book and/or U.S. passport card was issued AND my U.S. passport book and/or
Yes
No
U.S. passport card is less than one year old;
OR
My identifying information in my most recent U.S. passport book and/or U.S.
Yes
No
passport card was printed incorrectly;
OR
My most recent U.S. passport book was limited to two years or less for a
Yes
No
reason other than multiple losses or a seriously damaged/mutilated passport.
If you answered NO to ALL 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
travel.state.gov, or contact the National Passport Information Center for further information.
U.S. PASSPORTS, EITHER IN BOOK OR CARD FORMAT, ARE ISSUED ONLY TO U.S. CITIZENS OR NON-CITIZEN NATIONALS. EACH PERSON
MUST OBTAIN HIS OR HER OWN PASSPORT BOOK OR PASSPORT CARD. THE PASSPORT CARD IS A U.S. PASSPORT ISSUED IN CARD
FORMAT. LIKE THE TRADITIONAL PASSPORT BOOK, IT REFLECTS THE BEARER'S ORIGIN, IDENTITY, AND NATIONALITY AND IS SUBJECT TO
EXISTING PASSPORT LAWS AND REGULATIONS. UNLIKE THE PASSPORT BOOK, THE PASSPORT CARD IS VALID ONLY FOR ENTRY TO THE
UNITED STATES AT LAND BORDER CROSSINGS AND SEA PORTS OF ENTRY WHEN TRAVELING FROM CANADA, MEXICO, THE CARIBBEAN,
AND BERMUDA. THE U.S. PASSPORT CARD IS NOT VALID FOR INTERNATIONAL AIR TRAVEL.
INFORMATION, QUESTIONS, AND INQUIRIES
Please visit our website at travel.state.gov. In addition, you may contact the National Passport Information
Center (NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by email at NPIC@state.gov. Customer
Service Representatives are available Monday-Friday 8:00a.m.-10:00p.m. Eastern Time (excluding federal
holidays.) Automated information is available 24 hours a day, 7 days a week.
FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM, INCLUDING YOUR SOCIAL SECURITY NUMBER,
MAY RESULT IN SIGNIFICANT PROCESSING DELAYS AND/OR THE DENIAL OF YOUR APPLICATION.
NOTICE TO APPLICANTS RESIDING ABROAD
United States citizens residing outside the U.S. or Canada CANNOT submit this form to the domestic address listed on the Instruction Page 2. Such applicants
should contact the nearest U.S. Embassy or Consulate for procedures to be followed when applying overseas.
WARNING: False statements made knowingly and willfully in passport applications, including affidavits or other documents submitted to support
this application, are punishable by fine and/or imprisonment under U.S. law, including 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 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.
See page 2 of the instructions for detailed information on the completion and submission of this form.
If you choose to provide your email address in Item #6 on this application, Passport Services may use that information to contact you in the event there is a
problem with your application or if additional information is required.
DS-5504 06-2016
Instruction Page 1 of 4
APPLICATION FOR A U.S. PASSPORT
CORRECTIONS, NAME CHANGE WITHIN 1 YEAR OF PASSPORT ISSUANCE, AND LIMITED PASSPORT HOLDERS
PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS
Mailing Date of Application:____________________________
CAN I USE THIS FORM?
Complete this checklist to determine your eligibility to use this form
I have changed my name less than one year since my most recent U.S. passport
book and/or U.S. passport card was issued AND my U.S. passport book and/or
Yes
No
U.S. passport card is less than one year old;
OR
My identifying information in my most recent U.S. passport book and/or U.S.
Yes
No
passport card was printed incorrectly;
OR
My most recent U.S. passport book was limited to two years or less for a
Yes
No
reason other than multiple losses or a seriously damaged/mutilated passport.
If you answered NO to ALL 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
travel.state.gov, or contact the National Passport Information Center for further information.
U.S. PASSPORTS, EITHER IN BOOK OR CARD FORMAT, ARE ISSUED ONLY TO U.S. CITIZENS OR NON-CITIZEN NATIONALS. EACH PERSON
MUST OBTAIN HIS OR HER OWN PASSPORT BOOK OR PASSPORT CARD. THE PASSPORT CARD IS A U.S. PASSPORT ISSUED IN CARD
FORMAT. LIKE THE TRADITIONAL PASSPORT BOOK, IT REFLECTS THE BEARER'S ORIGIN, IDENTITY, AND NATIONALITY AND IS SUBJECT TO
EXISTING PASSPORT LAWS AND REGULATIONS. UNLIKE THE PASSPORT BOOK, THE PASSPORT CARD IS VALID ONLY FOR ENTRY TO THE
UNITED STATES AT LAND BORDER CROSSINGS AND SEA PORTS OF ENTRY WHEN TRAVELING FROM CANADA, MEXICO, THE CARIBBEAN,
AND BERMUDA. THE U.S. PASSPORT CARD IS NOT VALID FOR INTERNATIONAL AIR TRAVEL.
INFORMATION, QUESTIONS, AND INQUIRIES
Please visit our website at travel.state.gov. In addition, you may contact the National Passport Information
Center (NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by email at NPIC@state.gov. Customer
Service Representatives are available Monday-Friday 8:00a.m.-10:00p.m. Eastern Time (excluding federal
holidays.) Automated information is available 24 hours a day, 7 days a week.
FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM, INCLUDING YOUR SOCIAL SECURITY NUMBER,
MAY RESULT IN SIGNIFICANT PROCESSING DELAYS AND/OR THE DENIAL OF YOUR APPLICATION.
NOTICE TO APPLICANTS RESIDING ABROAD
United States citizens residing outside the U.S. or Canada CANNOT submit this form to the domestic address listed on the Instruction Page 2. Such applicants
should contact the nearest U.S. Embassy or Consulate for procedures to be followed when applying overseas.
WARNING: False statements made knowingly and willfully in passport applications, including affidavits or other documents submitted to support
this application, are punishable by fine and/or imprisonment under U.S. law, including 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 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.
See page 2 of the instructions for detailed information on the completion and submission of this form.
If you choose to provide your email address in Item #6 on this application, Passport Services may use that information to contact you in the event there is a
problem with your application or if additional information is required.
DS-5504 06-2016
Instruction Page 1 of 4
WHAT DO I SEND WITH THIS APPLICATION FORM?
1. Your most recent U.S. passport book and/or passport card.
2. A recent color photograph.
 Submit a color photograph of you alone, sufficiently recent to be a good likeness of you (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
photograph must be in color, clear, with a full front view of your face. The photograph must be taken with a neutral facial expression (preferred) or a natural
smile, and with both eyes open and be printed on photo quality paper with a plain light (white or off-white) background. The photograph must be taken in normal
street attire, without a hat or head covering unless a signed statement is submitted by the applicant verifying that the hat or head covering is part of recognized,
traditional religious attire that is customarily or required to be worn continuously when in public or a signed doctor's statement is submitted verifying the item is
used daily for medical purposes. Headphones, "bluetooth", or similar devices must not be worn in the passport photograph. Glasses or other eyewear are not
acceptable unless you provide a signed statement from a doctor explaining why you cannot remove them due to medical reasons (e.g., during the recovery
period from eye surgery). Any photograph retouched so that your appearance is changed is unacceptable. A snapshot, most vending machine prints, hand-held
self portraits, and magazine or full-length photographs are unacceptable. A digital photo must meet the previously stated qualifications, and will be accepted for
use at the discretion of Passport Services. Visit our website at travel.state.gov for details and information.
USE CAUTION WHEN STAPLING YOUR PHOTO: Use 4 staples vertically in the corners as close to the outer edges as possible. Do not bend the photo.
3. Evidence to submit with this form (all documentary evidence that is not damaged, altered, or forged will be returned to you):
 If your name has changed less than one year after your U.S. passport was issued AND your U.S. passport is less than one year old, you may use this
form. You must submit a certified name change document such as a certified copy of your marriage certificate or a certified copy of a court order showing a seal
and officiate/judge signature. 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) U.S. Embassy or Consulate, if abroad; (3) any federal or state court of record or any probate court accepting
passport applications; (4) a designated municipal or county official; or (5) a post office, which has been selected to accept passport applications.
 If there is a name change or an error in the descriptive data in your recently issued, unexpired passport, you must submit the appropriate evidence showing
the correct information (e.g. certified birth certificate or certified marriage certificate as described above).
 If you are re-applying because your U.S. passport book was limited in validity due to a lack of citizenship evidence or identity, you must submit evidence of
your U.S. citizenship (such as a government-issued birth certificate or a U.S. Certificate of Naturalization) and/or evidence of your identity (such as a driver's
license or a state issued identification card). You must establish your citizenship and identity to the satisfaction of Passport Services. We may ask you to
provide additional evidence to corroborate your claim to U.S. citizenship and/or your identity. Passports limited in validity due to serious damage or
multiple losses cannot be extended. Please contact the National Passport Information Center or visit travel.state.gov for more information and instructions.
 If your passport was limited due to gender transition, please visit http://travel.state.gov/content/passports/en/passports/information/gender.html for
information on what documentation you will need to submit with this application form.
HOW DO I APPLY USING THIS FORM?
1. Complete, sign, and date this form.
2. Send this form with your most recent U.S. passport book and/or passport card, any required additional evidence, and a recent color photograph.
MAIL FORM TO:
FOR ROUTINE SERVICE:
FOR EXPEDITED SERVICE (Requires a Fee):
National Passport Processing Center
National Passport Processing Center
Post Office Box 90107
Post Office Box 90907
Philadelphia, PA 19190-0107
Philadelphia, PA 19190-0907
Because of the sensitivity of the enclosed documents, Passport Services recommends using trackable mailing service when submitting your application.
IS THERE A FEE ASSOCIATED WITH THIS FORM AND HOW WILL MY NEW
U.S. PASSPORT BOOK AND/OR PASSPORT CARD BE MAILED BACK TO ME?
There is no fee associated with the use of this form unless expedited service is requested (see below). Your re-issued passport book and/or passport card and
any documentary evidence submitted to Passport Services will be returned to you by priority or first class mail, unless overnight delivery is requested. You may
receive your newly issued document and your returned citizenship evidence in separate mailings. If you are applying for both a U.S. passport book and card,
you may receive three separate mailings: one with your returned citizenship evidence; one with your newly issued U.S. passport book, and one with your newly
printed U.S. passport card.
OVERNIGHT DELIVERY SERVICE is only available for passport book (and not passport card) mailings in the United States. Please include the appropriate fee
with your application.
For faster processing, you may request expedited service. Please include the expedite fee with your application. Expedited service is only available for passports
mailed in the United States and Canada.
All fees must be submitted in the form of a personal check or money order. MAKE CHECKS PAYABLE TO "U.S. DEPARTMENT OF STATE." THE FULL
NAME AND DATE OF BIRTH OF THE APPLICANT MUST BE TYPED OR PRINTED ON THE FRONT OF THE CHECK. DO NOT SEND CASH. Passport
Services cannot be responsible for cash sent through the mail. Visit travel.state.gov for updated information on fees, processing times, or to check the status of
your passport application online.
NOTE REGARDING MAILING ADDRESSES: Passport Services does not send mail to a private addresses outside the United States or Canada. If you do not
live at the address listed in the "mailing address," then you must put the name of the person residing in that address and mark it as "In Care Of." If your mailing
address changes prior to receipt of your new U.S. passport, please call the National Passport Information Center at 1-877-487-2778 or visit travel.state.gov.
DS-5504 06-2016
Instruction Page 2 of 4
NOTICE TO CUSTOMERS APPLYING OUTSIDE A DEPARTMENT OF STATE FACILITY
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.
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.
FEE REMITTANCE
Passport service fees are established by law and regulation (see 22 U.S.C. 214, 22 C.F.R. 22.1, and 22 C.F.R. 51.50-56) 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 your credit card, the U.S. Department of State will take action to collect the
delinquent fees from you under 22 C.F.R. Part 34, and the Federal Claims Collection Standards (see 31 C.F.R. 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 U.S. Department of State will refer the debt to the U.S. Department of Treasury for collection. Debt collection procedures used by the U.S.
Department of 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. In addition, non-payment of passport
fees may result in the invalidation of your passport. An invalidated passport cannot be used for travel.
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.
IMPORTANT NOTICE TO APPLICANTS WHO HAVE LOST OR HAD A PREVIOUS U.S. PASSPORT BOOK
AND/OR PASSPORT CARD STOLEN
A United States citizen may not normally bear more than one valid or potentially valid U.S. passport book or more than one valid or potentially valid
U.S. passport card at a time. Therefore, when a valid or potentially valid U.S. passport book or U.S. passport card cannot be presented with a new
application, it is necessary to submit a Form DS-64, Statement Regarding a Lost or Stolen U.S. Passport. Your statement must detail why the
previous U.S. passport book or U.S. passport card cannot be presented.
The information you provide regarding your lost or stolen U.S. passport book or passport card will be placed into our Consular Lost or Stolen
Passport System. This system is designed to prevent the misuse of your lost or stolen U.S. passport book or passport card. Anyone using the
passport book or passport card reported as lost or stolen may be detained upon entry into the United States. Should you locate the U.S. passport
book or passport card reported lost or stolen at a later time, report it as found, and submit it for cancellation. It has been invalidated. You may not
use that passport book or passport card for travel.
PROTECT YOURSELF AGAINST IDENTITY THEFT!
REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD!
For more information or to report your lost or stolen U.S. passport book or passport card by phone, call NPIC or visit our website at travel.state.gov.
SPECIAL NOTICE TO U.S. PASSPORT CARD APPLICANTS ONLY
The maximum number of letters provided for your given name (first and middle) on the U.S. Passport Card is 24 characters. The 24 characters may be
shortened due to printing restrictions. If both your given names are more than 24 characters, you must shorten the given name you list on item 1 of this form.
FEDERAL TAX LAW
Section 6039E of the Internal Revenue Code (26 U.S.C. 6039E) and 22 U.S.C 2714a(f) require you to provide your Social Security number (SSN), if you
have one, when you apply for or renew a U.S. passport. If you have never been issued a SSN, you must 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 U.S. Department of the Treasury. If you fail to provide the information, your application may be denied and you are
subject to a $500 penalty enforced by the IRS. All questions on this matter should be referred to the nearest IRS office.
USE OF SOCIAL SECURITY NUMBER
Your Social Security number will be provided to U.S. Department of Treasury, used in connection with debt collection and checked against lists of
persons ineligible or potentially ineligible to receive a U.S. passport, among other authorized uses.
DS-5504 06-2016
Instruction Page 3 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/nationality, 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.
Furthermore, I have not been convicted of a federal or state drug offense or convicted for “sex tourism” crimes statute, and I am not the subject of
an outstanding federal, state, or local warrant of arrest for a felony; a criminal court order forbidding my departure from the United States; a
subpoena received from the United States in a matter involving federal prosecution for, or grand jury investigation of, a felony.
PRIVACY ACT STATEMENT
AUTHORITIES: Collection of this information is authorized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E, 22 U.S.C. 2714a(f),
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 C.F.R. parts 50 and 51.
PURPOSE: We are requesting this information in order to determine your eligibility to be issued a U.S. passport. Your Social Security number is
used to verify your identity.
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 information on this form is voluntary. Be advised, however, that failure to provide the information requested on this form
may cause delays in processing your U.S. passport application and/or could result in the refusal or denial of your application.
Failure to provide your Social Security number may result in the denial of your application (consistent with 22 U.S.C. 2714a(f)) and may subject you
to a penalty enforced by the Internal Revenue Service, as described in the Federal Tax Law section of the instructions to this form. Your Social
Security number will be provided to the Department of the Treasury and may be used in connection with debt collection, among other purposes
authorized and generally described in this section.
ELECTRONIC PASSPORT STATEMENT
The U.S. Department of State now issues an "Electronic Passport" book, which contains an embedded electronic chip. The electronic passport
book continues to be proof of the bearer's United States citizenship/nationality and identity, and looks and functions in the same way as a passport
without a chip. The addition of an electronic chip in the back cover enables the passport book to carry a duplicate electronic copy of all information
from the data page. The electronic passport book is usable at all ports-of-entry, including those that do not yet have electronic chip readers.
Use of the electronic format provides the traveler the additional security protections inherent in chip technology. Moreover, when used at
ports-of-entry equipped with electronic chip readers, the electronic passport book provides for faster clearance through some of the port-of-entry
processes.
The electronic passport book does not require special handling or treatment, but like previous versions should be protected from extreme heat,
bending, and from immersion in water. The electronic chip must be read using specially formatted readers, which protects the data on the chip
from unauthorized reading.
The cover of the electronic passport book is printed with a special symbol representing the embedded chip. The symbol
will appear in
port-of-entry areas where the electronic passport book can be read.
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 40 minutes per response, including the 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 unless this 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: Passport Forms Officer, U.S. Department of State,
CA/PPT/S/L, 44132 Mercure Cir, P.O. Box 1227, Sterling, Virginia 20166-1227.
DS-5504 06-2016
Instruction Page 4 of 4
OMB CONTROL NO. 1405-0160
APPLICATION FOR A U.S. PASSPORT
OMB EXPIRATION DATE: 10-31-2019
NAME CHANGE, DATA CORRECTION, AND LIMITED PASSPORT BOOK REPLACEMENT
ESTIMATED BURDEN: 40 MIN
Please Print Legibly Using Black Ink Only
Attention: Read WARNING on page 1 of instructions
Please select the document(s) for which you are applying:
U.S. Passport Book
U.S. Passport Card
Both
The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions.
Regular Book (Standard)
Large Book (Non-Standard)
Note: The large book option is for those who frequently travel abroad during the passport validity period and is
recommended for applicants who have previously required the addition of visa pages.
1. Name Last
D
O
DP
DOTS Code
End. #
Exp.
First
Middle
2. Date of Birth (mm/dd/yyyy)
3. Sex
4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.)
M
F
-
-
6. Email (Info alerts offered at travel.state.gov)
5. Social Security Number
7. Primary Contact Phone Number
-
-
-
-
@
8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.
Address Line 2: Clearly label Apartment, Company, Suite, Unit, Building, Floor, In Care Of or Attention if applicable. (e.g., In Care Of - Jane Doe, Apt # 100)
City
State
Zip Code
Country, if outside the United States
9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed.)
A.
B.
10. U.S. Passport Book and/or Passport Card Information
Your name as printed on your most recent U.S. passport book and/or passport card
Most recent U.S. passport book number
Book Issue Date (mm/dd/yyyy)
Card Issue Date (mm/dd/yyyy)
Most recent U.S. passport card number
Attach a color photograph
taken within the last six months
CONTINUE TO PAGE 2
YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW
I declare under penalty of perjury all of the following: 1) I am a citizen or non-citizen national of the United States and have not, since acquiring U.S. citizenship or nationality,
performed any of the acts listed under "Acts or Conditions" on page four of the instructions of this application (unless explanatory statement is attached); 2) the statements made on
the application are true and correct; 3) I have not knowingly and willfully made false statements or included false documents in support of this application; 4) the photograph
submitted with this application is a genuine, current photograph of me; and 5) I have read and understood the warning on page one of the instructions to the application form.
x
Applicant's Legal Signature - age 16 and older
Date
FOR ISSUING OFFICE ONLY
x
Mother/Father/Parent/Legal Guardian's Signature (if identifying minor)
Name Change
Replacement
Correction:
LName
FName
MName
DOB
Sex
POB
Other
From:
To:
BC
Nat/Citz Cert
Report of Birth
Prev PPT
MC
Adoption C/O
NC C/O
PIERS
Other
Filed/Issued/Place:
Doc #:
Other:
Attached:
Postage
Other
EF
* DS 5504 C 11 2013 1 *
DS-5504 06-2016
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