109331 USGPO~~Statement Regarding A Valid Lost or Stolen ...

1 Department of StateOMB Control No. 1405-0014 Expiration Date: Estimated Burden: 5 MinutesPage 1 of 2DS-64 +2: 72 5(3257 $ 9$/,' /267 25 672/(1 3$663257 %22. $1' 25 &$5'To report a Valid lost or Stolen passport ERRN DQG RU FDUG please choose ONEof the following : Visit our website at PHONE: Call 1-877-487-2778 (TDD: 1-888-874-7793) and follow the representative's instructions. This option is notavailable for customers MAIL: Submit this formANDa front and back photocopy of a government-issued photo identification (such as a driver'slicense or state-issued identification) to the following address ONLY IFyou areNOTapplying for a new book and/or card: ATTN: Department of State CA/PPT/S/50 &/$63 44132 Mercure Cir Box 1227 Sterling, VA 20166-1227 * Only use this address to submit this form or other correspondence about lost/ Stolen passports.))

2 For general inquiries, call theNational Passport Information Center at yourself against identity theft! Report a lost or Stolen passport! For more information, please visit our website: :$51,1*False statements made knowingly and willfully on this form, in passport applications, or in affidavits or other supporting documents submitted therewith are punishable by fine and/or imprisonment under law, including the provisions of 18 and/or 18 1542. Alteration or mutilation of a passport is punishable by fine and/or imprisonment under the provisions of 18 1543.

3 The use of a passport in violation of the restrictions contained therein or of the passportregulations is punishable by fine and/or imprisonment under 18 1544. All statements and documents submitted are subject to ,9$&< $&7 67$7(0(17 AUTHORITIES: We are authorized to collect this information by 22 211a et seq.; 8 1104; 8 1737; ExecutiveOrder 11295(August 5, 1966); and 22 Parts 50 and : 7he information UHTXHVWHG RQ WKLV IRUP LV XVHG to ensure that no one has more than one Valid passport bookDQG RQH YDOLG 8 6 passport card at any one time, except as authorized by the Department of State, and to combat passportIUDXG DQG PLVXVH 7he collection of the Social Security number will be used to verify the identity of the person reporting the lostRU VWROHQ SDVVSRUW DQG to identify the passport being reported lost or Stolen .))

4 There is no other purpose unless authorized by :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 $3(5:25. 5('8&7,21 $&7 67$7(0(17 Public reporting burden for this collection of information is estimated to average five minutes per response, including time requiredfor searching existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection.))))

5 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:3 DVVSRUW )RUPV 2 IILFHU Department of State, Bureau of Consular Affairs, Passport Services, Office of Program ManagementDQG 2 SHUDWLRQDO Support, 44132 Mercure Cir., Box 1199, Sterling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

6 RU D PRUH GHWDLOHG OLVWLQJ RI WKH URXWLQH XVHV WR ZKLFK WKLV LQIRUPDWLRQ PD\ EH SXW SOHDVH VHH WKH 'HSDUWPHQW RI 6 WDWH V 3 UHIDWRU\ 6 WDWHPHQW RI 5 RXWLQH 8 VHV 3 XEOLF 1 RWLFH RI -XO\ DQG WKH OLVWLQJ RI URXWLQH XVHV VHW IRUWK LQ WKH 6\VWHP RI 5 HFRUGV 1 RWLFHV IRU 2 YHUVHDV &LWL]HQ 6 HUYLFHV 5 HFRUGV DQG 2 WKHU 2 YHUVHDV 5 HFRUGV 6 WDWH DQG 3 DVVSRUW 5 HFRUGV 6 WDWH STATEMENT Regarding A Valid LOST OR Stolen PASSPORT BOOK AND/OR CARD,I \RXU PRVW UHFHQW ORVW RU VWROHQ SDVVSRUW LV H[SLUHG LW LV QR ORQJHU YDOLG DQG \RX GR QRW QHHG WR VXEPLW WKLV IRUP 2. WHILE APPLYING FOR A NEW PASSPORT: Submit this form with a new DS-11, Application for D Passport along ZLWK required documentation to any designated acceptance facility, passport agency, embassy, or consulate Department of StateSTATEMENT Regarding A Valid LOST OR Stolen PASSPORT BOOK AND/OR CARDOMB Control No.

7 1405-0014 Expiration Date: Estimated Burden: 5 MinutesPage 2 of 2DS-64 IMPORTANT NOTICE A national may not normally bear more than one Valid or potentially Valid passport book and/or card at a time. Therefore, a statement is required when applying for a new passport if the previously Valid or potentially Valid passport is not submitted. Your statement must detail Zhy the previous Valid 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 Valid lost or Stolen passports.

8 If more than one Valid passport previously issued to you was lost or Stolen , your replacement passport may be limited in validity. ONCE REPORTED, THE Valid LOST OR Stolen PASSPORT IS ELECTRONICALLY CANCELLED AND CANNOT 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 PassportBookLost StolenValid PassportCardLost StolenAre you submitting this form in connection with an application for a new passport book and/or card?

9 Yes NoLast NameFirst NameMiddle NameHas your name changed since the passport was issued? If yes, state the name in which the YDOLG lost or Stolen passport was of Birth (mm-dd-yyyy)Place of Birth (City & State if in or City & Country)Social Security Number Current Address (Street, City, State, and ZIP Code or Country, if outside the )Telephone NumberAlternative Telephone NumberEmail Address$QVZHU DOO TXHVWLRQV FRPSOHWHO\ ,I \RX GR QRW NQRZ WKH DQVZHU LQ GHWDLO EH DV H[DFW DV SRVVLEOH 7KH SDVVSRUW ERRN DQG FDUG KDYH GLIIHUHQW QXPEHUV 3 OHDVH SURYLGH WKH FRUUHFW QXPEHU V LI NQRZQ 7KH SDVVSRUW QXPEHU RQ D ORVW RU VWROHQ SDVVSRUW FDQQRW EH UHXVHG Explainin detailhow your Valid passport book/card was lost or Stolen .]

10 Include a photocopy of the Valid passport book/card if where the loss or theft occurred. Provide the address, if known(City and State, if in the , or City and Country as it is presently known)On what date was your Valid passport book/card lost or Stolen (mm-dd-yyyy)? If unknown, when was the last time you remember it being in your possession? Did you file a police report? (If yes and the report is available, please submit a copy.) Yes NoList your Valid lost or Stolen Passport Book, if known: List your Valid lost or Stolen Passport Card, if known: NumberIssueDate(mm-dd-yyyy)NumberIssueDa te(mm-dd-yyyy)Have you had any other Valid passport book/card lost or Stolen ?