Application For A U.s. Passport Corrections, Name Change Within 1 Year Of Passport Issuance, And Limited Passport Holders Page 6
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6Name of Applicant (Last, First & Middle)
Date of Birth (mm/dd/yyyy)
11. Height
12. Hair Color
13. Eye Color
15. Employer or School (if applicable)
14. Occupation (if age 16 or older)
16. Additional Contact Phone Numbers
Home
Cell
Home
Cell
Work
Work
17. 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
18. 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
19. Travel Plans
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Countries to be visited
Please complete the following questions regarding your current passport book and/or passport card
Has your name changed by marriage or court
Current Name Last
order less than one year after your U.S.
passport book or passport card was issued?
Yes
No
First
Middle
If yes, and your submitted passport book and/or
passport card is less than one year old, please
complete this section with your current information.
Note: You must submit evidence documenting your name change (such as a certified marriage certificate or court order) and your current U.S. passport
book and/or passport card, along with this completed form to the address listed on page 2 of the instructions.
If you can not or did not meet the above criteria, please complete Form DS-82, U.S. Passport Renewal Application for Eligible Individuals or Form DS-11,
Application for a U.S. Passport.
Was your identifying information printed
Name Last
incorrectly in your U.S. passport book or passport
card?
Middle
First
Yes
No
If yes, please complete the information as it should
appear, and check only the box(s) next to the
Place of Birth (State or Country)
Date of Birth (mm/dd/yyyy)
Sex
field(s) to be corrected.
M
F
Please submit evidence documenting your correct identifying information (such as a certified marriage certificate or birth certificate) and your
current U.S. passport book and/or passport card, along with this completed form to the address listed on page 2 of the instructions.
Note: To complete a limited U.S. passport book replacement, your submitted U.S.
Was your most recent U.S. passport limited for
passport book must not be expired. Passport books limited in validity because of
two years or less?
multiple losses, damages, or mutilations cannot be extended.
Yes
No
Please be sure to enclose your U.S. passport book along with this application to the
If yes, please submit evidence of your U.S. citizenship (such as a U.S.
address listed on page 2 of the instructions.
birth certificate or naturalization certificate) and/or evidence of your
identity (such as a driver's license or a state-issued ID card). Visit
gender.html for information regarding gender transition documentation.
* DS 5504 C 11 2013 2 *
DS-5504 06-2016
Page 2 of 2
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