70e62629 6071 400e Abd8 61aca740943d
: Littlebits 70E62629-6071-400E-Abd8-61Aca740943D 70e62629-6071-400e-abd8-61aca740943d 105967 user uploads
Open the PDF directly: View PDF .
Page Count: 6
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 herein 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.
APPLICANTS WHO HAVE HAD A PREVIOUS U.S. PASSPORT BOOK AND/OR PASSPORT CARD
- AS DIRECTED BY PUBLIC LAW 106-113 AND 22 CFR 51.28:
To submit an application for a child under age 16 both parents or the child's legal guardian(s) must appear and present the following:
- Evidence of the child's U.S. citizenship;
- Evidence of the child's relationship to parents/guardian(s); AND
- Original parental/guardian government-issued identification AND a photocopy of the front and back side of presented identification.
IF ONLY ONE PARENT APPEARS, YOU MUST ALSO SUBMIT ONE OF THE FOLLOWING:
- Second parent's notarized written statement or DS-3053 (including the child's full name and date of birth) consenting to the passport issuance for the child.
The notarized statement cannot be more than three months old and must be signed and notarized on the same day, and must come with a photocopy of
the front and back side of the second parent's government-issued photo identification; OR
- Second parent’s death certificate if second parent is deceased; OR
- Primary evidence of sole authority to apply, such as a court order; OR
- A written statement or DS-5525 (made under penalty of perjury) explaining in detail the second parent's unavailability.
- AS DIRECTED BY REGULATION 22 C.F.R. 51.21 AND 51.28:
- Each minor child applying for a U.S. passport book and/or passport card must appear in person.
REQUIREMENTS FOR CHILDREN
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.
FOR INFORMATION AND QUESTIONS
Visit the official Department of State website at travel.state.gov or contact the National Passport Information
Center (NPIC) via toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) and 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.
U.S. PASSPORT APPLICATION
DS-11 06-2016 Instruction Page 1 of 4
WHAT TO SUBMIT WITH THIS FORM:
1. PROOF OF U.S. CITIZENSHIP: Evidence of U.S. citizenship AND a photocopy of the front (and back, if there is printed information) must be submitted
with your application. The photocopy must be on 8 ½ inch by 11 inch paper, black and white ink, legible, and clear. Evidence that is not damaged, altered,
or forged will be returned to you. Note: Lawful permanent resident cards submitted with this application will be forwarded to U.S. Citizenship and
Immigration Services, if we determine that you are a U.S. citizen.
2. PROOF OF IDENTITY: You must present your original identification AND submit a photocopy of the front and back with your passport application.
3. RECENT COLOR PHOTOGRAPH: Photograph must meet passport requirements – full front view of the face and 2x2 inches in size.
4. FEES: Please visit our website at travel.state.gov for current fees.
HOW TO SUBMIT THIS FORM:
Complete and submit this application in person to a designated acceptance agent: a clerk of a federal or state court of record or a judge or clerk of a probate
court accepting applications; a designated municipal or county official; a designated postal employee at an authorized post office; an agent at a passport
agency (by appointment only); or a U.S. consular official at a U.S. Embassy or Consulate, if abroad. To find your nearest acceptance facility, visit
travel.state.gov or contact the National Passport Information Center at 1-877-487-2778.
LOST OR STOLEN - If you cannot submit your valid or potentially valid U.S. passport book and/or passport card with this application and you have
not previously submitted Form DS-64, Statement Regarding a Lost or Stolen U.S. Passport, you are required to fill out and submit a DS-64 with this
IN MY POSSESSION - If your most recent U.S.passport book and/or passport card was issued less than 15 years ago, and you were over the age of
16 at the time of issuance, you may be eligible to use Form DS-82 to renew your passport by mail.
Follow the instructions on Page 2 for detailed information to completion and submission of this form.
If you are 16 years of age or older: Your U.S. passport will be valid for 10 years from the date of issue except where limited by the Secretary of State to a
If you are under 16 years of age: Your U.S. passport will be valid for five years from the date of issue except where limited by the Secretary of State to a
PASSPORT VALIDITY LENGTH
PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS
- The passport application fee, security surcharge, and expedite fee may be paid in any of the following forms: Checks (personal, certified, or
traveler's) with the applicant's full name and date of birth printed on the front; major credit card (Visa, Master Card, American Express, and Discover); bank
draft or cashier's check; money order (U.S. Postal, international, currency exchange), or if abroad, the foreign currency equivalent, or a check drawn on a
U.S. bank. All fees should be payable to the "U.S. Department of State" or if abroad, the appropriate U.S. Embassy or U.S. Consulate. When applying at a
designated acceptance facility, the execution fee will be paid separately and should be made payable to the acceptance facility. NOTE: Some designated
acceptance facilities do not accept credit cards as a form of payment.
- For faster processing, you may request expedited service. Please include the expedite fee in your payment. Our website contains updated information
regarding fees and processing times for expedited service. Expedited service is only available for passports mailed in the United States and Canada.
- OVERNIGHT DELIVERY SERVICE is only available for passport book mailings in the United States. Please include the appropriate fee with your payment.
- An additional fee will be charged when, upon your request, the U.S. Department of State verifies issuance of a previous U.S. passport or Consular Report
of Birth Abroad because you are unable to submit evidence of U.S. citizenship.
- For applicants with U.S. government or military authorization for no-fee passports, no fees are charged except the execution fee when applying at a
designated acceptance facility.
PROOF OF U.S. CITIZENSHIP
You may submit items such as the following containing your signature AND a photograph that is a good likeness of you: previous or current U.S. passport
book; previous or current U.S. passport card; driver's license (not temporary or learner's license); Certificate of Naturalization; Certificate of Citizenship;
military identification; or federal, state, or municipal government employee identification card. Temporary or altered documents are not acceptable.
You must establish your identity to the satisfaction of the acceptance agent and Passport Services. We may ask you to provide additional evidence to
establish your identity. If you have changed your name, please see travel.state.gov for instructions.
IF YOU CANNOT PROVIDE DOCUMENTARY EVIDENCE OF IDENTITY as stated above, you must appear with an IDENTIFYING WITNESS, who is a U.S.
citizen, non-citizen U.S. national, or permanent resident alien that has known you for at least two years. Your witness must prove his or her identity and
complete and sign an Affidavit of Identifying Witness (Form DS-71) before the acceptance agent. You must also submit some identification of your own.
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.
FEES ARE LISTED ON OUR WEBSITE AT TRAVEL.STATE.GOV. BY LAW, THE PASSPORT FEES ARE NON-REFUNDABLE.
PROOF OF IDENTITY
Instruction Page 2 of 4
APPLICANTS BORN IN THE UNITED STATES: Submit a previous U.S. passport or certified birth certificate. Passports that are limited in validity will need
to be supplemented by other evidence. A birth certificate must include your full name, date and place of birth, sex, date the birth record was filed, the seal or
other certification of the official custodian of such records (state, county, or city/town office), and the full names of your parent(s).
- If the birth certificate was filed more than 1 year after the birth: It must be supported by evidence described in the next paragraph.
- If no birth record exists: Submit a registrar's notice to that effect. Also, submit a combination of the evidence listed below, which should include your given
name and surname, date and/or place of birth, and the seal or other certification of the office (if customary), and the signature of the issuing official.
- A hospital birth record;
- An early baptismal or circumcision certificate;
- Early census, school, medical, or family Bible records;
- Insurance files or published birth announcements (such as a newspaper article); and
- Notarized affidavits (or DS-10, Birth Affidavit) of older blood relatives having knowledge of your birth may be submitted in addition to
some of the records listed above.
APPLICANTS BORN OUTSIDE THE UNITED STATES: Submit a previous U.S. passport, Certificate of Naturalization, Certificate of Citizenship, Consular
Report of Birth Abroad, or evidence described below:
- If you claim citizenship through naturalization of parent(s): Submit the Certificate(s) of Naturalization of your parent(s), your foreign birth certificate (and
official translation if the document is not in English), proof of your admission to the United States for permanent residence, and your parents'
marriage/certificate and/or evidence that you were in the legal and physical custody of your U.S. citizen parent, if applicable.
- If you claim citizenship through birth abroad to at least one U.S. citizen parent: Submit a Consular Report of Birth (Form FS-240), Certification of Birth (Form
DS-1350 or FS-545), or your foreign birth certificate (and official translation if the document is not in English), proof of U.S. citizenship of your parent, your
parents' marriage certificate, and an affidavit showing all of your U.S. citizen parents' periods and places of residence/physical presence in the United States
and abroad before your birth.
- If you claim citizenship through adoption by a U.S. citizen parent(s): Submit evidence of your permanent residence status, full and final adoption, and your
U.S. citizen parent(s) evidence of legal and physical custody. (NOTE: Acquisition of U.S. citizenship for persons born abroad and adopted only applies if the
applicant was born on or after 02/28/1983.)
ADDITIONAL EVIDENCE: You must establish your citizenship to the satisfaction of the acceptance agent and Passport Services. We may ask
you to provide additional evidence to establish your claim to U.S. citizenship. Visit travel.state.gov for details.
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.
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.
NOTICE TO CUSTOMERS APPLYING OUTSIDE A DEPARTMENT OF STATE FACILITY
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 Department will refer the debt to the U.S. Department of Treasury for collection. Debt collection procedures used by 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.
USE OF SOCIAL SECURITY NUMBER
For more information regarding reporting a lost or stolen U.S. passport book or passport card (Form DS-64), or to determine your eligibility for a
passport renewal (Form DS-82), call NPIC at 1-877-487-2778 or visit travel.state.gov.
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.
PROTECT YOURSELF AGAINST IDENTITY THEFT!
REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD!
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.
Passport Services will not mail a U.S. passport to a private address 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 and mark it as "In Care Of" in item # 8. If your mailing address changes prior to receipt of your
new passport, please contact the National Passport Information Center.
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 you need to provide information to us.
You may receive your newly issued passport book and/or card and your returned citizenship evidence in two separate mailings. If you are applying for both
a U.S. passport book and passport card, you may receive three separate mailings; one with your returned citizenship evidence, one with your newly issued
passport book, and one with your newly issued passport card.
NOTICE TO U.S. PASSPORT CARD APPLICANTS
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 one of your given names you list on item 1 of
U.S. passports, either in book or card format, are only issued to U.S. citizens or non-citizen U.S. nationals. Each person must obtain his or her own U.S.
passport book or U.S. passport card. The passport card is a U.S. passport issued in card format. Like the traditional U.S. passport book, it reflects the
bearer's origin, identity, and nationality, and is subject to existing passport laws and regulations. Unlike the U.S. passport book, the U.S. passport card is
valid only for entry 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.
NOTE REGARDING MAILING OF YOUR PASSPORT(S)
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 of a "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 U.S. 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
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 85 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: U.S. Department of State, Bureau of Consular Affairs,
Passport Services, Office of Legal Affairs and Law Enforcement Liaison, 44132 Mercure Cir, P.O. Box 1227, Sterling, Virginia 20166-1227
Instruction Page 4 of 4
4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.)
APPLICATION FOR A U.S. PASSPORT
DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY AUTHORIZED AGENT
OMB CONTROL NO. 1405-0004
OMB EXPIRATION DATE: 08-31-2019
ESTIMATED BURDEN: 85 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:
End. # Exp.
STOP! CONTINUE TO PAGE 2
U.S. Passport Card
U.S. Passport Book
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.
Large Book (Non-Standard)
City Zip Code
6. Email (Info alerts offered at travel.state.gov)7. Primary Contact Phone Number
1. Name Last
Country, if outside the United StatesState
9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed)
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)
Mother/Father/Parent/Legal Guardian's Signature (if identifying minor)
Mother/Father/Parent/Legal Guardian's Signature (if identifying minor)
Applicant's Legal Signature - age 16 and older
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 attached to 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.
Acceptance Agent (Vice) Consul USA
Passport Staff Agent
* DS 11 B 09 2013 1 *
Bk Postage Execution Other
For Issuing Office Only
Identifying Documents - Applicant or Mother/Father/Parent on Second Signature Line (if identifying minor)
DS-11 06-2016 Page 1 of 2
Facility ID Number
Agent ID Number
Signature of person authorized to accept applications
Passport Military Other
State Issued ID Card
Identifying Documents - Applicant or Mother/Father/Parent on Third Signature Line (if identifying minor)
STAPLE 2" x 2" STAPLE
STAPLE 2" x 2" STAPLE
Attach a color photograph
taken within the last six months Name
(mm/dd/yyyy) Exp. Date
(mm/dd/yyyy) State of
Passport Military Other
8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.
5. Social Security Number
2. Date of Birth (mm/dd/yyyy)
Regular Book (Standard)
The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions.
State Issued ID Card
Name of courier company (if applicable)
(mm/dd/yyyy) Exp. Date
(mm/dd/yyyy) State of
03 15 1988
593 74 1258
PANAMA CITY, FL
150 MYRTLE AVENUE
BROOKLYN NY 11201
18. Travel Plans
Departure Date (mm/dd/yyyy) Return Date (mm/dd/yyyy) Countries to be Visited
19. 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)
13. Occupation (if age 16 or older) 14. Employer or School (if applicable)
12. Additional Contact Phone Number
Mother/Father/Parent - First & Middle Name Last Name (at Parent's Birth)
Date of Birth (mm/dd/yyyy) Place of Birth
10. Parental Information
Date of Birth (mm/dd/yyyy)Name of Applicant (Last, First, & Middle)
Mother/Father/Parent - First & Middle Name Last Name (at Parent's Birth)
Date of Birth (mm/dd/yyyy) Place of Birth
If yes, complete the remaining items in #11.
Date of Marriage
11. Have you ever been married?
Full Name of Current Spouse or Most Recent Spouse Date of Birth (mm/dd/yyyy)
Have you ever been widowed or divorced?
Place of Birth
Yes No Widow/Divorce Date
15. Height 16. Hair Color 17. Eye Color
City Zip CodeState
21. Have you ever applied for or been issued a U.S. Passport Book or Passport Card?
Name as printed on your most recent passport book
Yes No If yes, complete the remaining items in #21.
PLEASE DO NOT WRITE BELOW THIS LINE - FOR ISSUING OFFICE ONLY
20. 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
Name as printed on your most recent passport card
Status of your most recent passport book: Submitting with application Stolen Lost In my possession (if expired)
Status of your most recent passport card: Submitting with application Stolen Lost In my possession (if expired)
Most recent passport book number Most recent passport book issue date (mm/dd/yyyy)
Most recent passport card number Most recent passport card issue date (mm/dd/yyyy)
* DS 11 B 09 2013 2 *
DS-11 06-2016 Page 2 of 2
Name as it appears on citizenship evidence
Birth Certificate SR CR City Filed: Issued:
Passport C/R S/R Per PIERS #/DOI:
P/C of ID DS-5520DS-3053 DS-64 DS-5525 PAWDS-71 NPIC IRL Citz W/S
Report of Birth Filed/Place:
Nat. / Citz. Cert. USCIS USDC Date/Place Acquired: A#
P/C of Citz
SOUTHWORTH, THOMAS CLAYTON 03/15/1988
5ft. 11in. BLACK BROWN
03/01/2017 03/06/2017 BAHAMAS
WANA COOK 1575 RIVERTRACE DRIVE
FLEMING ISLAND FL 32003 904-703-3866 MOTHER