Fill and Sign the Passport Renewal Application Form

U.S. Department of State APPLICATION FOR A U.S. PASSPORT BY MAIL DS-82 05-2006 Instruction Page 1 of 4 PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS. Date of Application See Instruction Page 2 for Detailed Information on the Completion and Su bmission of this form. INCOMPLETE OR UNACCEPTABLE APPLICATIONS WI LL DELAY THE ISSUANCE OF YOUR PASSPORT. CAN I USE THIS FORM? Complete this checklist to determine your eligibility to use this form. If you answered NO to any of the four statements above, STOP - You cannot use this form!!! You must apply on application form DS-11 by making a personal appearance before a pa ssport agent, postal clerk, or clerk of court authorized to accept passport applications. 1. I can submit my most recent U.S. passport. 2. I was at least 16 years old when my most recent U.S. passport was issued. 3. I was issued my most recent U.S. passport less than 15 years ago. 4. I use the same name as on my most recent U.S. passport. -- OR -- Yes Yes Please visit our website at travel.state.gov. In addition, contact the National Passport Information Center (NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by e-ma il at NPIC@state.gov. Customer Service Representatives are available M-F, 8AM-8PM EST (excluding Federal holidays). Yes Y es NOTICE TO APPLICANTS RESIDING ABROAD United States citizens residing abroad CANNOT submit this form to the passport facility listed on instructions page 2. Su ch a p pl ic ants s h ould c ont act the n ear est Un it ed St ates em bas sy or con su late f o r pro ce d ures to be f o llo w ed w hen applying overseas. FOR INFORMATION, QUESTIONS, AND INQUIRIES (mm-dd-yyyy) No No No No YOUR MOST RECENT U.S. PASSPORT. Issued at age 16 or older in your current name (or see item #2 below) and issued within the past 15 years. If your U.S. passport is damaged, you must apply on the DS- 11 application form as specified below. A MARRIAGE CERTIFICATE OR COURT ORDER. If the name you are currently using differs from the name on your most recent passport, you must submit a marriage certificate or court orde r showing the change of name. The name change document MUST bear the official seal of the issuing authority. Uncertified copies or notarized documents cannot be accepted. All documents will be returned to you with your passport. If you are unable to document your name change in this manner, you must apply on the DS-11 application form by making a personal appearance at (1) a passport agency; (2) any clerk of a Federal, State or county c ourt of record or an probate court accepting passport applications; or (3) a Post Office which has been selected to accept pass port applications. THE FEE OF $67. Enclose the $67 fee in the form of a personal check or money order. MAKE CHECKS PAYABLE TO "U.S. DEPARTMENT OF STATE". THE FULL NAME AND DATE OF BIRTH OF THE APPLICANT MUST BE TYPED OR PRINTED ON THE FRONT OF THE CHECK. DO NOT SEND CASH. Passport Services cannot be responsible for cash sent through the mail. By law, the fee is non -refundable. For faster processing, you may request expedited service. Expedited requests will be processed in three workdays from receipt at a passport agency. The additional fee for expedited service is $60. Therefore, if you choose to request expedited service the total cost of you U.S. passport will be $127. Expedited service is available only in the United States. If you desire SPECIAL POSTAGE SERVICE (overnight mail , special delivery, etc.), include the appropriate postage fee on the check or include a pre-paid envelope. If you choose to provide your e-mail address in Item #15 on this application, Passport Services will only use that information to contact you in the event there is a problem with your application or if yo u need to provide additional information to us. WHAT DO I NEED TO SEND WITH THE APPLICATION FORM? 1. Your most r ecent U.S. passport 2 . A marriage certificate or court order if your name has changed 3. Fee of $67 (If requesting expedited service, the total fee will be $127) 4. Two recent, color photographs See below for more detailed information. TWO RECENT, COLOR PHOTOGRAPHS. Submit two color photographs of you alone, sufficiently recent to be a good likeness of you (normally taken within the last six months), and 2x2 inches in size. The image size measured from the bottom of the 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 photographs must be color, clear, with a full front view of your face, and printed on thin paper with plain light (white or off-white) background. They must be capable of withstandin g a mounting temperature of 225 Fahrenheit (107 Celsius). Photographs must be taken in norm al street attire, without a hat, head covering, or dark glasses unless a signed statement is submitted by the applicant verifying the item is worn daily for religious purposes or a sign ed doctor's statement is submitted verifying the item is used daily for medical purposes. Photographs retouched so that your appearance is changed are unacceptable. Snapshots, most vending machine prints, and magazine or full-length photographs are unacceptable. Digitized photos must meet the previously stated qualifications and will be accepted for use at the discretion of Passport Services. (Visit our website for details.) 1. 2. 3. 4. NOTE WHERE DO I MAIL THIS APPLICATION ? DS-82 Instruction Page 2 of 4 DELIVERY - Other Than U.S. Postal Service MAIL THIS FORM TO National Passport Processing Po st Office B ox 13349 P hiladelphia , PA 19101-3349 FOR INQU IR IES CONTACT N ation al P as sp ort In fo rm atio n Cen ter 1-877 -487-2 778 F o r TD D: 1- 888-87 4-7793 E-mail: NPIC@state.govW eb si te : trave l .stat e .g o v National Passport Processing At tn : Department 13349 1617 Brett RoadNew Castle, DE 19720 DS-82Instruction Page 3 of 4 FEDERAL TAX LAW Section 6039E of the Internal Revenue Code (26 U.S.C. 6039 E) requires you to provide your Social Security Number (SSN), if you have one, when you apply for a U.S. passport or renewal of a U.S. passport. If you have not been issued a SSN, enter zeros in box #5 of this form. If you are residing abroad, you must also provide the nam e of the foreign country in which you are residing. The U.S. Department of State must provide your SSN a nd foreign residence information to the Department of Treasury. If you fail to provide the information, you are subjec t to a $500 penalty enforced by the IRS. All questions on this matter should be directed to the nearest IR S 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 che ck. The debit from your account will usually occur within 24 hours, and will be shown on your regular account statement. NOTICE TO CUSTOMERS M AKING PAYMENT BY CHECK 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 origina l check. If the EFT cannot be completed because of insufficient funds, we may try to make the transfer up to tw o times and we will charge you a one-time fee of $25, which we will also collect by EFT. 31 U.S.C. 7701 requires persons "doing business" with a federal agency to provide their security numbers to that agency. Because the U.S. Department of State collects fees for the provision of passport serv ices to you, you are considered a person "doing business" with the Department. Passport service fees are esta blished by law and regulation (see 22 U.S.C. 214, 22 CFR 22.1, and 22 CFR 51.61-66) and are collected at th e 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 you credit card, the U.S. Department of State will take action to collect the delinquent fees from you under 22 CFR Part 34 and the Federal Claims Collection Standards (see 31 CFR 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 Department of Treasury for collection. Debt co llection procedures used by Treasury may include referral of the debt to private collection agencies, reporting of the de bt to credit bureaus, garnishment of private wages and administrative offset of the debt by reducing or withholdin g eligible Federal payments (e.g. tax refunds, social security payments, federal retirement, etc.) by the amount of your debt, including any int erest penalties or other costs incurred. PAYMENT OF FEES In addition, non-payment of passport fees will result in the invalidation of your passport. An invalidated passport cannot be used for travel. In addition to reporting your Social Security Number to Tr easury and using it in connection with debt collection, the Department checks Social Security Numbers against lists of pe rsons ineligible or potentially ineligible to receive a U.S. passport. OTHER USES OF SOCIAL SECURITY NUMBERS PAPERWORK REDUCTION STATEMENT You are not required to provide the information requested on this form unless the f orm displays a currently valid OMB number. We try to create forms and instructions that can be easily understood. Often this is d ifficult to do because our citizenship laws are very complex. The estimated burden time for this information collection is 40 minutes, which includes the time required to search existing data sources, gather the necessary data, com plete and review this form, and provide and submit the form and any additional information required. If you have comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we would be happy to hear from you. You c a n write u s at: U. S. D ep artm ent of St ate (A/ ISS /DIR), W ash in gt on, DC 2 05 20. IMPORTANT NOTICE TO APPLICANTS WHO HAVE LOST OR HAD A PREVIOUS PASSPORT STOLEN A United States citizen may not normally bear more than one valid or potentially valid U.S. passport at a time. It therefore is necessary to submit a statement with an application for a new U.S. passport whe n a previous valid or potentially valid U.S. passport cannot be presented with an application for a new passport. Your statement must detail why the previous U.S. passport cannot be presented. The information you provide regarding your lost or stolen U.S. passport will be placed into our Consular Lost or Stolen Passport System. This system is designed to prevent the misuse of your lost or stolen U.S. passport. Anyone using the passport book reported as lost or stolen may be detained upon entry into the United States. Should you locate the U.S. passport reported lost or stolen at a later time, report it as found and submit it for cance llation. It has been invalidated. You may not use that passport for travel. PROTECT YOURSELF AGAINST IDENTITY THEFT - REPORT YOUR LOST OR STOLEN PASSPORT! For more information or to report your lost or stolen passport by phone, call NPIC or visit our website at t ravel.state.gov. AUTHORITIES Collection of the information solicited on this form is authorized by Titles 8, 22, and 26 of the Unit ed States Code, whether or not codified, including specifically 22 U.S.C. 211a et seq.; 26 U.S.C. 6039E, 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 CFR parts 50 and 51. PURPOSE The primary purpose for soliciting the information is to establish citizenship, identity, and entitleme nt to issuance of a U.S. passport. ROUTINE USES The information solicited on this form may be made available as a routine use to other government agencies to assist the U.S. Department of State in adjudica ting passport applications and requests for related services, and for law enforcement and administration purposes. The information may be made avai lable to foreign government agencies to fulfill passport control and immigration duties. The information may also be provided to foreign government agencies, international organizations and, in limited cases, private persons and organizations to investigate, prosecute, or otherwise address potential violations of law or to furt her the Secretary's responsibility for the protection of U.S. citizens and non-citizen nationals abroad. The information may be made available to private U.S. cit izen 'wardens' designated by the U.S. embassies and consulates. For a more detailed listing of the routine uses to which this information may be put, see the Prefatory Statement of Routine Uses and the listing of routine . users set forth in the system descriptions for Overseas Citizen Services Records (S tate-05) and Passport Records (State-26) published in the Federal Register. DS-82 Instruction Page 4 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 affirm ation) by the applicant should be attached and made a part of this application.) I have not, since acquiring United Stat es citizenship, been naturalized as a citizen of a foreign state; taken an oath or made an affirmation or other for mal 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 thereo f; made a formal renunciation of nationality either in the Un ited 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 co mmitting any act of treason against, or attempting by force to overthrow, or bearing arms against, the Unite d States, or conspiring to overthrow, put down, or to destroy by force, the Government of the United States. PRIVACY ACT STATEMENT CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION With the exception of your Social Security Number (see Federal Tax Law statement on Instruction Page 3), you are not legally required to provide the information requested on this form. However, failure to do so may result in Passport Services' refusal to accept your application or result in the denial of a U.S. passport. ELECTRONIC PASSPORT STATEMENT The U.S. Department of State will begin issuing a new type of passport containing an embedded electr onic chip and called an "Electronic Passport". The new passport will continue to be proof of the bearer's Unite d States citizenship and identity, and will look and function in the same way as a pass port without a chip. The addition of an electronic chip in the back cover will enable the new passport to carry a duplicate electronic copy of all information from the data page. The new passport will be usable at all ports-of-entry, including those that do not yet have el ectronic chip readers. Use of the electronic format will provide the traveler the ad ditional security protections inherent in chip technology. Moreover, when used at ports-of-entry equipped with electronic chip readers, the new passp ort will provide for faster clearance through some of the port-of-entry processes. Issuance of this new passport will be phased in during an 18 -month period. It is expected that by late-2006 nearly all U.S. passports will be issued in this new format. The new passport will not require special handling or treatmen t, but like previous versions should be protected from extreme bending and from immersion in water. The electronic chip must be read using specially formatted readers, and is not susceptible to unauthorized reading. The cover of the new passport will be printed with a special symbol representing the embedded chip. The symbol will appear in port-of-entry areas where the electronic passport can be read. 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. WARNING False statements made knowingly and willfully in passport applications, including affidavits or other supporting docu ments submitted therewith, are punishable by fine and/or imprisonment under 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 impr isonment under the provisions of 18 U.S.C. 1543. The use of a passport in violation of the restrictions contained therein or of the passport regulations is punis hable by fine and/or imprisonment under 18 U.S.C. 1544. All statements and documents are subject to verification. You must submit your most recent U.S. passport with this form! If you cannot submit your most recent U.S. passport, apply on Form DS-1 1, Application For A U.S. Passport. 2" x 2" Submit two recent, color photographs 2" x 2" 4. Place of Birth (City & State OR City & Country) Street / RFD Number OR Post Office Box City STOP 16. Passport Information APPLICATION FOR A U.S. PASSPORT BY MAIL U.S. Department of State DS-82 05-2006 Page 1 of 2 1. Name of Applicant OMB APPROVAL NO. 1405-0020 EXPIRATION DATE: 08/31/2008 ESTIMATED BURDEN: 40 Minutes (See Instruction Page 3) 11. Mail My New Passport To ( ) ( ) Name in Which Most Recent Passport was Issued Most Recent U.S. Passport Number Issue Date of Most Recent U.S. Passport When completing this form, PRINT IN BLUE OR BLACK INK ONLY. 2. Date of Birth 3. Sex Male Female 5. Social Security Number (See Federal Tax Law Notice on Instruction Page3) Last Suffix First Middle FeetInches 6. Height 7. Hair Color 8. Eye Color 9. Occupation 10. Employer 12. Permanent Address or Residence (If Same as Mailing Address Write "Same As Above") Street / RFD Number (DO NOT LIST P.O. BOX) Apartment Number City State ZIP Code Apartment Number State ZIP Code In Care of (If Applicable) Country (If Outside the U.S.) 15. E-Mail Address (Optional) 13. Home Telephone (Include Area Code) 14. Business Telephone (Include Area Code) Issue Date R D O DP End. # Exp. (mm-dd-yyyy) (Jr., Sr., III) Telephone( ) DS-82 Page 2 of 2 Name of Applicant Date of Birth (mm-dd-yyyy) 17. Travel Plans Date of Trip (mm-dd-yyyy) Countries to be Visited Length of Trip 18. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency. Name State ZIP Code 19. Oath & Signature E-Mail Address (Optional) Relationship Apartment Number Street / RFD Number Applicant's Signature X Date (mm-dd-yyyy) DO NOT WRITE BELOW - FOR PASSPORT SERV ICES USE ONLY - DO NOT WRITE BELOW Evidence of Name Change Marriage Certificate Court Order Document Issue Date Place of Issue Issuing Office/Court Previous Name Current Name APPLICATION APPROVAL FEE EXEC. EF OTHER City You must sign and date this application in the designated area below! NOTE I declare under penalty of perjury that I am a United States ci tizen (or non-citizen national) and have not, since acquiring United State citizenship (or U.S. nationality), performed any of the acts listed under "Acts or Conditions" on the reverse of this application form (unless explanatory statement is attached). I declare under penalty of perjury that the st atements made on this application are true and correct. (Last, First, Middle, Suffix)