Fillable Form Ds-11 - Family Guardian (Page 4 of 4) in pdf

U.S. Department of State

APPLICATION FOR U.S. PASSPORT OR REGISTRATION

FEDERAL TAX LAW

26 U.S.C. 6039E (Internal Revenue Code) requires a passport applicant to provide his or her name and social security

number. If you have not been issued a social security number, enter zeros in box #6. The U.S. Department of State must

provide this information to the Internal Revenue Service routinely.

Any applicant who fails to provide the required

information is subject to a $500 penalty enforced by the IRS. All questions on this matter should be referred to the

nearest IRS office.

ACTS OR CONDITIONS

(If any of the below-mentioned acts or conditions has 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.

WARNING: False statements made knowingly and willfully in passport applications or in affidavits or other supporting

documents submitted therewith are punishable by fine and/or imprisonment under provisions of 18 U.S.C. 1001 and/or 18

U.S.C. 1542.

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 submitted are subject to verification.

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 noted, 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

administration 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 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 20 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.

DS-11

Page 4 of 4

Form Ds-11 - Family Guardian Page 4

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