OMB CONTROL NO. 1405-0014 OMB EXPIRATION DATE: 11-30-2021 ESTIMATED BURDEN: 5 Minutes. Statement regarding a lost or stolen u.s...
U.S. Department of State STATEMENT REGARDING A LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD HOW TO REPORT A LOST OR STOLEN PASSPORT BOOK AND/OR CARD To report a lost or stolen passport, please choose ONE of the following options: 1. To apply for a new U.S. passport book and/or card please submit this form with a new DS-11, Application for a U.S. Passport, to any designated acceptance facility, U.S. passport agency, U.S. embassy, or U.S. consulate abroad. OR 2. Report a lost or stolen U.S. passport online by visiting our website at travel.state.gov. OR 3. Report a lost or stolen U.S. passport by phone by calling 1-877-487-2778 (TDD: 1-888-874-7793) and following the representative's instructions. OR 4. Submit this form by mail AND a photocopy of a government-issued photo identification (such as a driver's license or state-issued identification) to the following address* ONLY IF you are NOT applying for a new U.S. passport book and/or card: ATTN: CLASP U.S. Department of State CA/PPT/S/L/LE 44132 Mercure Cir P.O. Box 1227 Sterling, VA 20166-1227 * Only use this address to submit this form or other correspondence about lost/stolen passports. For general inquiries, call the National Passport Information Center at 1-877-487-2778. Protect yourself against identity theft! Report a lost or stolen U.S. passport! For more information, please visit our website: travel.state.gov WARNING False statements made knowingly and willfully on this form, in U.S. passport applications, or in affidavits or other supporting documents submitted therewith are punishable by fine and/or imprisonment under U.S. law, including the provisions of 18 U.S.C. 1001 and/or 18 U.S.C. 1542. Alteration or mutilation of a U.S. passport is punishable by fine and/or imprisonment under the provisions of 18 U.S.C. 1543. The use of a U.S. 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 STATEMENT AUTHORITIES: We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 8 U.S.C. 1737; Executive Order 11295 (August 5, 1966); and 22 C.F.R. Parts 50 and 51. PURPOSE: We are requesting the information to ensure that no one has more than one valid U.S. passport book and one valid U.S. passport card at any one time, except as authorized by the U.S. Department of State, and to combat passport fraud and misuse. The collection of the Social Security number will be used to verify the identity of the person reporting the lost or stolen passport and to identify the passport being reported lost or stolen. There is no other purpose unless authorized by law. 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 information can be found in System of Records Notices State-05, Overseas Citizen Services Records and Other Overseas Records and State-26, Passport Records. DISCLOSURE: Providing your Social Security number and other information on this form is voluntary, but failure to provide the information on this form may, given the form's purpose of verification of your identity, result in processing delays. PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is estimated to average five minutes per response, including 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, Attn: Passport Forms Officer, 44132 Mercure Cir., P.O. Box 1227, Sterling, VA 20166-1227. DS-64 07-2018 Page 1 of 2 U.S. Department of State Please Print Legibly Using Black Ink Only OMB CONTROL NO. 1405-0014 OMB EXPIRATION DATE: 11-30-2021 ESTIMATED BURDEN: 5 Minutes STATEMENT REGARDING A LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD IMPORTANT NOTICE A U.S. national may not normally bear more than one valid or potentially valid U.S. passport book and/or card at a time. Therefore, a statement is required when applying for a new U.S. passport if the previously valid or potentially valid passport is not submitted. Your statement must detail why the previous U.S. passport cannot be presented. The information you provide on this form will be placed into the Consular Lost and Stolen Passport System, which is designed to prevent the misuse of all reported lost or stolen passports. If more than one U.S. passport previously issued to you was lost or stolen, your replacement passport may be limited in validity. Once reported, the lost or stolen passport is electronically cancelled and MUST NOT BE USED FOR TRAVEL. Anyone (including the bearer) traveling on a reported lost or stolen passport may be detained upon entering the United States. Should you locate the passport after reporting it lost or stolen, submit it for cancellation to the Consular Lost and Stolen Passport Unit (CLASP). See page one of this form for contact information. Please select the document (or documents) that you are reporting and its status. U.S. Passport Book Lost U.S. Passport Card Stolen Lost Stolen 1. IDENTIFYING INFORMATION OF PASSPORT HOLDER: Type or print legibly in black ink in white areas only. Last Name First Name Middle Name Has your name changed since the passport was issued? If yes, state the name in which the lost or stolen passport was issued. Sex Female Date of Birth (mm-dd-yyyy) Male Place of Birth (City & State if in U.S. or City & Country) Current Address (Street, City, State, and ZIP Code or Country, if outside the U.S.) Social Security Number Telephone Number ( ) Alternative Telephone Number ( ) E-mail Address 2. LOST OR STOLEN U.S. PASSPORT BOOK/CARD INFORMATION: Answer all questions completely. If you do not know the answer in detail, be as exact as possible. Are you submitting this form in connection with an application for a new U.S. passport book and/or card? Yes No Explain how your U.S. passport book/card was lost or stolen. Explain where the loss or theft occurred. Provide the address, if known (City and State, if in the U.S., or City and Country as it is presently known) On what date was your U.S. passport book/card lost or stolen (mm-dd-yyyy)? If unknown, when was the last time you remember it being in your possession? List your lost or stolen U.S. Passport Book, if known: Number Issue Date (mm/dd/yyyy) Have you had any other U.S. passport book/card lost or stolen? Yes List your lost or stolen U.S. Passport Card, if known: Number Issue Date (mm/dd/yyyy) No If yes, how many passports? Approximate date(s)? Did you file a police report? Yes No (If yes and the report is available, please submit a copy.) 3. YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW I, the undersigned, declare under penalty of perjury all of the following: 1) that I have read and understood the warning on page one of this form; 2) the information provided herein is correct and complete; 3) I have not given my U.S. passport book and/or passport card to another person or disposed of it in an unauthorized manner; 4) I understand that the U.S. passport(s) I report as missing will be invalidated and cannot be used; and 5) if I subsequently find and recover it, I will immediately return the passport and/or passport card to Passport Services at the address on page one of this form or to the nearest U.S. passport agency, U.S. embassy or U.S. consulate, if abroad, and I will not attempt to use it. Legal Signature - age 16 or older or Parent/Guardian if under age 16 Date (mm/dd/yyyy) Legal Signature - Parent/Guardian if under age 16 Date (mm/dd/yyyy) Both parents or guardians of a child younger than 16 years old must sign and provide photocopy of ID when submitting this form on the child's behalf unless one parent or guardian has sole custody. If there is sole custody, include a copy of a supporting document, such as a court order, with this form. DS-64 07-2018 Page 2 of 2Acrobat Distiller 11.0 (Windows)