U.S. Department of State STATEMENT REGARDING …

1 If you are applying for a new passport book and/or card, please submit this form with a new DS-11 passport application to anydesignated acceptance facility, passport agency, embassy, or consulate abroad. If you are not currently applying for a new passport book and/or card, send this form or a recovered lost or stolen book and/or card to the following address: Department of StatePassport ServicesConsular Lost/Stolen Passport UnitAttn: CLASP600 19th Street, NWWashington, DC 20522To report a lost or stolen passport by telephone, call: 1-877-487-2778, For more information, please visit our website: www.

2 : We are authorized to collect this information by 22 211a et seq.; 8 1104; 26 6039E; Executive Order 11295(August 5, 1966); and 22 parts 50 and : We are requesting the information to ensure that no one has more than one passport book and one passport card at any onetime, except as authorized by the 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 no otherpurpose unless authorized by 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.

3 These routine uses include, but are not limited to, lawenforcement activities, employment verification, fraud prevention, border security, counterterrorism, litigation activities, and activities that meet theSecretary of State 's responsibility to protect citizens and non-citizen nationals information on the Routine Uses for the system can be found in System of Records Notices State -05, Overseas Citizen Services Records andState-26, Passport : Providing your Social Security number and other information on this form is voluntary, but failure to provide the information on thisform may, given the form's purpose of verification of your identity, result in processing delays or the denial of your passport application.

4 False statements made knowingly and willfully on this form, in passport applications, or in affidavits or other supporting documents submittedtherewith are punishable by fine and/or imprisonment under law, including the provisions of 18 1001 and/or 18 1542. Alterationor mutilation of a passport is punishable by fine and/or imprisonment under the provisions of 18 1543. The use of a passport inviolation of the restrictions contained therein or of the passport regulations is punishable by fine and/or imprisonment under 18 1544.

5 Allstatements and documents submitted are subject to ACT STATEMENTPAPERWORK REDUCTION ACT STATEMENTP ublic reporting burden for this collection of information is estimated to average ten minutes per response, including time required for searchingexisting data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection. Youdo not have to supply this information unless this collection displays a currently valid OMB control number.

6 If you have comments on the accuracyof this burden estimate and/or recommendations for reducing it, please send them to: Department of State , Bureau of Consular Affairs,Passport Services, Office of Program Management and Operational Support, 2201 C Street NW, Washington, address should only be used to submit this form or other correspondence about lost/stolen passports. It should not be used forgeneral inquiries that are unrelated to lost/stolen TO REPORT YOUR LOST OR STOLEN PASSPORT BOOK AND/OR PASSPORT Department of StateSTATEMENT REGARDING A LOST OR STOLEN PASSPORT BOOK AND/OR CARDIf you are submitting this form without also submitting a passport application, please provide a copy of agovernment-issued photo identification, such as a driver's license or a State -issued identification card.

7 DS-64 08-2013 Page 1 of 2 ATTN: Department of StateCA/PPT/S/L/LE4th Floor1150 Passport Services PL Dulles, VA 20189-1150 Protect yourself against identity theft! Report a lost or stolen passport book or passport card!Middle NameFirst NameLast NameDate of Birth (mm-dd-yyyy) E-mail AddressWork Telephone NumberSocial Security NumberHas your name changed since the passport was issued? If yes, State the name in which the lost or stolen passport was List your lost or stolen Passport Book:2. LOST OR STOLEN PASSPORT BOOK/CARD INFORMATION:Place of Birth (City & State if in or City & Country)List your lost or stolen Passport Card:FemaleMaleHome Telephone Number()()Current Address (Street, City, State , and ZIP Code)IssueDate (mm/dd/yyyy)Number:IssueDate: (mm/dd/yyyy): Number:Answer all questions completely.

8 If you do not know theanswer in detail, be as exact as possible. 2a. Explain how the document(s) were lost or Explain where the loss or theft occurred. Provide Address if known (City/ State )2c. On what date was your document(s) lost or stolen? (mm-dd-yyyy). If unknown, when was the last time you remember it in your possession? 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 furnished herein is correct and complete; 3) I have not given my passport book and/or passport card to another person ordisposed of it in an unauthorized manner; 4) I understand that the passport(s) I report as missing will be invalidated and cannot be used.

9 And 5)if I subsequently find and recover it, I will immediately return it to Passport Services at the address on page one of this form or to the nearest agency, embassy, or consulate a child under 16, this form must be signed by both parents or the child's legal guardian(s). In case of sole custody, include a copy of thesupporting document (court order) with this REGARDING A LOST OR STOLEN PASSPORT BOOK AND/OR Department of StateOMB CONTROL NO. 1405-0014 OMB EXPIRATION DATE: 08/31/2015 ESTIMATED BURDEN: 10 MinutesPage 2 of 21.

10 IDENTIFYING INFORMATION: Type or print legibly in black ink in white areas select the document (or documents) which you are reporting and their status. Passport CardLostLostStolenStolen Passport Book IMPORTANT NOTICEA citizen may not normally bear more than one valid or potentially valid passport book and one valid passport card at a time. Ittherefore is necessary to submit a STATEMENT with an application for a new passport when a previously issued valid or potentially valid book/card cannot be presented.