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Date Created: 04/20/16
U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS Date of Application:_____________________ CAN I USE THIS FORM? Complete the checklist to determine your eligibility to use this form I can submit my most recent U.S. passport book and/or U.S. passport Yes No card with this application. I was at least 16 years old when my most recent U.S. passport book and/or passport card was issued. Yes No I was issued my most recent U.S. passport book and/or passport card less than 15 years ago. Yes No My most recent U.S. passport book and/or U.S. passport card that I am renewing has not been lost, stolen, mutilated, or damaged. Yes No My U.S. passport has not been limited from the normal ten year validity period due to passport damage/mutilation, multiple passport thefts/losses, or non-compliance with 22 C.F.R. 51.41. (Please Yes No refer to the back pages of your U.S. passport book for endorsement information.) I use the same name as on my recent U.S. passport book and/or U.S. passport card. --OR-- Yes No I have had my name changed by marriage or court order and can submit proper documentation to reflect my name change. If you answered NO to any of the statements above, STOP - You cannot use this form! You must apply on application form DS-11 by making a personal appearance before an acceptance agent authorized to accept passport applications. Visit travel.state.gov to find your nearest acceptance facility. 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 U.S. 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. PLEASE NOTE: YOUR NEW PASSPORT WILL HAVE A DIFFERENT PASSPORT NUMBER THAN YOUR PREVIOUS PASSPORT. 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 abroad 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 submi tted 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 finent under theisonm provisions of 18 U.S.C. 1543. The use of a passport in violation of the restrictions contained therein or of the passport regu lations 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. DS-82 08-2013 Instruction Page 1 of 4 WHAT DO I SEND WITH THIS APPLICATION FORM? Your most recent U.S. passport book and/or card; A certified copy of your marriage certificate or court order if your name has changed; Fees; and A recent color photograph. See below for more detailed information. 1. YOUR MOST RECENTLY ISSUED U.S. PASSPORT (BOOK AND/OR CARD FORMAT). Submit your most recently issued U.S. passport book and/or card. When submitting a U.S. passpor t book and/or card with this form, please verify that the document was issued at age 16 or older in your current name (or see item #2 below) and issued within the past 15 years. You are also eligible to use this form if you currently have a U.S. passport book and/or card that complies with the previously listed criteria, and would like to obtain a alternative product (U.S. passport book and/or card) for the first time. However, you must submit the product you currently have (U.S. passport book and/or card) with this application. If your U.S. passport book and/or card has been lost, stolen, damaged, or mutilated, you must apply on the DS-11 application form as specified below. 2. A CERTIFIED MARRIAGE CERTIFICATE OR COURT ORDER. (PHOTOCOPIES ARE NOT ACCEPTED) If the name you are currently using differs from the name on y our most recent U.S. passport, you must submit a certified copy of your marriage certificate or court order showing the change of name. All documents will be re turned to you by mail. If you are unable to document your nam e 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 passp ort applications; (4) a designated mu nicipal or county official; o r (5) a post office, which has been selected to accept passport applications. 3. THE CURRENT PASSPORT FEE. Enclose the fee in the form of a personal check or money ordMAKE CHECKS PAYABLE TO "U.S. DEPA RTMENT 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. By law, the fees are non-refundable. Please visit our website at travel.state.gov for detailed information regarding current fees. OVERNIGHT DELIVERY SERVICE : If you desire overnight delivery service for the return of y our U.S. passport, please include the appropriate fee with your payment. FASTER PROCESSING: For an additional fee, you may request expedited service. Pleas e include this fee in your payment and submit the application to the appropriate address.Please write "Expedite" on the outer envelope when mailing. Also, TO ENSURE MINIMAL PROCESSING TIME for expedited passport book applications, Passport Services recommends using overnight delivery when submitting the application AND including the appropriate postage fee for return overnight delivery for the newly issued passport booExpedited service is available only in the United States. Overnight return delivery is only available for passport books. Please visit travel.state.gov for updated information regarding fees, processing times, or to check the status of your passport application online. 4. A RECENT COLOR PHOTOGRAPH. Submit a color photograph of you alone, sufficiently recent to be a good likenes(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 n ot more than 1 3/8 inches. The photograph must be color, clear, with a full front viewface, and printed on thin paper with plain light (white or off- white) background. The photograph must be taken in normal street attire, without a hat, head cove ring, 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 purp oses. Headphones, "bluetooth", or similar devices must not be worn in the passport photograph. Any photograph retouchethat your appearance is changed is unacceptable. A snapshot, most vending machine prints, 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. Please visit our website at travel.state.gov for details and information. WHERE DO I MAIL THIS APPLICATION? FOR ROUTINE SERVICE: FOR EXPEDITED SERVICE (Additional Fee): National Passport Processing Center National Passport Processing Center Post Office Box 90155 Post Office Box 90955 Philadelphia, PA 19190-0155 Philadelphia, PA 19190-0955 Due to the sensitivity of the enclosed documents, Passport Services recommends using trackable mailing service when submitting your application. NOTE REGARDING MAILING ADDRESSES: Passport Services will not mail a passport to a private address outside the United States. If you do not live at the address listed in the "mailing address", then you must put the name of the person and mark it as "In Care Of." If your mailing address changes prior to receipt of your new passport, please contact the National Passport Information Center (NPIC) at 1-877-487-2778 or visit travel.state.gov NOTE: You may receive your newly issued document and your returned citi zenship evidence in separate mailings. If you are applying f or both a passport book and/or card, you may receive three separate mailings; one with your returned citizenshi p evidence; one with your newly issued passport book, and one with your newly printed passport card. If you choose to provide your email address in Item #6 on this application, Passport Services may use that address to contact you in the event there is a problem with your application or if additional information is required. DS-82 08-2013 Instruction Page 2 of 4 FEDERAL TAX LAW Section 6039E of the Internal Revenue Code (26 USC 6039E) requires you to provide your Social Security number (SSN), if you hav e one, when you apply for a U.S. passport or renewal of a U.S. pass port. If you have not been issued SSN, enter zeros in box #5 of this form. If you are residing abroad, you must also provide the name of the foreign c ountry 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 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. NOTICE TO CUSTOMERS APPLYING OUTSIDE A STATE DEPARTMENT FACILITY If you send us a check, it will be converted into an electroniunds transfer (EFT). This means we will copy your check and u se 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 ba ck. We will destroy your original check, but we will keep the copy of it. If the E FT cannot be processed for technical reasons, you authorize us to process the copy in pl ace 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. REMITTANCE OF FEES Passport service fees are established by law and regulation (s ee 22 U.S.C. 214, 22 C.F.R. 22.1, and 22 C.F.R. 51.50-56), and ar e collected at the time you apply for the passport service. If the Department fails to receive full payment of the applicable fees because, for e xample, your check is returned for any reason or you dispute a pass port fee charge to your credit card, the US. Department of State will take actionto 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 Department will refer the debt to the U. S. Department of Treasury for collectDebt collection procedures used by the U .S. Department of Treasury may include referral of the debt to private collecti on 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 penaltie s or other costs incurred. In addition, non-payment of passpo rt fees may result in the invalidation of your U.S. passport book and/or card. An invalidated passport card cannot be used for travel. OTHER USES OF SOCIAL SECURITY NUMBER Your Social Security number will be provided to the 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 book and/or card, among other authorized uses. NOTICE TO APPLICANTS FOR OFFICIAL, DIPLOMATIC, OR NO-FEE PASSPORTS You may use this application if you meet al l of the provisions listed on Instruction Page 2, however, you must CONSULT YOUR SPO NSORING 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 pr esented with a new application, it is necessary to submit a Fo rm DS-64, Statement Regarding a Lost or Stolen U.S. Passpor t. Your statement must d etail 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 Unit ed 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 U.S. 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 at: 1-877-487-2778 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 (firand middle) on the U.S. passport card is 24 characters. T24 characters may be shortened due to printing restrictions. If both your given names are more than 24 characters, you must shorten one of your given names you list on item 1 of this form. DS-82 08-2013 Instruction Page 3 of 4 ACTS OR CONDITIONS If any of the below-mentioned acts or conditi ons have been performed by or apply to the applicant, the portion which applies sh ould 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 ci tizenship/nationality, been naturalized as a citizen of a foreign state; taken an o ath or made an affirmation or other formal decla ration of allegiance to a foreign state; entered or served in the armed forces of a foreign st ate; accepted or performed the duties of any office, post, or employment under the government of a fo reign state or politic al subdivision thereo f; 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 forc e 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 of fense 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; 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 requested in order to verify your identity. Failure to provide yo ur Social Security number on t his form may delay processing of your application. ROUTINE USES: This information may be disclosed to another domestic gover nment 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, borde r 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 the other information on this form is voluntary, but failure to provide the informa tion on this form may, given the form's purpose of verification of ident ity and entitlement to a U.S. pa ssport, result in processing de lays or denial of the passport application. Failure to provide your Social Security nu mber may also subject you to a penalty enforc ed by the Internal Revenue Service, as d escribed 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 as authorized and generally described in this section. Provid ing your Social Security number and other information requested on this form is otherwise voluntary. ELECTRONIC PASSPORT STATEMENT The U.S. Department of State now issues an "Electronic Passport" book, which contains an embedded electronic chip. The electro nic passport book continues to be proof of the bearer's United States citizenship/nationality and identity, and looks and functions in the s ame 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 secu rity protections inherent inchip technology. Moreover, when used at ports-of-entry equipped with electronic chip readers, the electronic passport book prov ides for faster clearance through some o f the port-of-entry processes. The electronic passport book does not requir e special handling or treatment, but like previous versions should be protected fro m 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 es timated to average 40 minutes per response, including the time required for searching existing data sources, gathering the nece ssary data, providing the information and/or documentation requir ed, 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 c omments on the accuracy of this burden estimate and/or recomme ndations for reducing it, please send th em 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. DS-82 08-2013 Instruction Page 4 of 4 OMB CONTROL NO. 1405-0020 U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS OMB EXPIRATION DATE: 12-31-2016 Please Print Legibly Using Black Ink Only ESTIMATED BURDEN: 40 MIN 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. 28 Page Book (Standard) 52 Page Book (Non-Standard) Note: The 52 page 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 5. Social Security Number 6. Email Address (e.g., email@example.com) 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. Passport Book and/or Passport Card Information STAPLEYour name as printed on your most recent U.S. passport book and/or passport card 2Most recent passport book number Issue date (mm/dd/yyyy) STAPLE Most recent passport card number Issue date (mm/dd/yyyy) STAPLE 2" x 2" 11. Name Change Information Complete if name is different than last U.S. passport book or passport card Changed by Marriage Place of Name Change (City/State) Date (mm/dd/yyyy) STAPLE Changed by Court Order Attach a color photograph taken within the last six months Please submit a certified copy. (Photocopies are not accepted!) 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 followia citizen or non-citizen national of the United States and hav e 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 knowingl y and willfully made false statements or included false document s 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 Date FOR ISSUING OFFICE ONLY PPT BK C/R PPT BK S/R PPT CD C/R PPT CD S/R Marriage Certificate Date of Marriage/Place Issued: Court Order Date Filed/Court: From To: Other: Attached: For Issuing Office Only Bk Fee Cd Fee EF Postage Other * DS 82 C 08 2013 1 * DS-82 08-2013 Page 1 of 2 Name of Applicant (Last, First & Middle) Date of Birth (mm/dd/yyyy) 12. Height 13. Hair Color 14. Eye Color 15. Occupation 16. Employer or School (if applicable) 17. Additional Contact Phone Numbers Home Cell Home Cell Work Work 18. Permanent Address: If P.O. Box is listed under Mailing Address or if residence is different from Mailing Address. Street/RFD # or URB (No P.O. Box) Apartment/Unit City State Zip Code 19. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency. Name Address: Street/RFD # or P.O. Box Apartment/Unit City State Zip Code Phone Number Relationship 20. Travel Plans Departure Date (mm/dd/yyyy) Return Date (mm/dd/yyyy) Countries to be visited STOP! YOU HAVE COMPLETED YOUR APPLICATION BE SURE TO SIGN AND DATE PAGE ONE * DS 82 C 08 2013 2 * DS-82 08-2013 Page 2 of 2
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