Application For A U.s. Passport Corrections, Name Change Within 1 Year Of Passport Issuance, And Limited Passport Holders (Page 3 of 6) in pdf

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