Form DS-86 Statement of Non-Receipt of a Passport

OMB Approval No.: 1405-0146
Expires: xx-xx-xxxx
*Estimated Burden: 5 Minutes

U.S. Department of State

STATEMENT OF NON-RECEIPT OF A PASSPORT
IMPORTANT NOTICE
A United States citizen may not normally bear more than one valid or potentially valid passport book and one valid
passport card at a time. The information you provide on the DS-86, Statement of Non-Receipt of a Passport, will be
placed into our Consular Lost or Stolen Passport System. This system is designed to prevent the misuse of your U.S.
passport. Anyone using the passport book or passport card reported on the DS-86, including yourself, may be
detained upon entry into the United States. Should you locate the passport you reported as non-received at a later
time, report it as found and submit it for cancellation. It has been invalidated. You may not use that passport for
travel. See page 2 of this form for additional information.

Protect yourself against identity theft! Report the non-receipt of your passport book or passport card!
Type or print legibly in blue or black ink in white areas only.
Please select the document(s) which you are reporting.

Passport Book

Passport Card

Last Name

First Name

Middle Name

Date of Birth (mm-dd-yyyy)

Home Telephone Number

Work Telephone Number

Address to which passport was to be mailed

Street Address

Apartment Number

City

State

ZIP Code

Where was the previous application filed? (Check one only.)
Clerk of Court
Passport Agent
Postal Employee

City/State/Country

(Vice) Consul USA

Date (mm-dd-yyyy)

Mailed (Renewals)
I, the undersigned, certify that I filed an application for a passport of the type(s) specified above on the date and at the place shown above. I further
attest that I have not received the passport book and/or passport card for which the application was filed. I declare under penalty of perjury that the
statements made on this form are true and correct. I request that a passport be issued to me and certify that if the passport previously applied for is
received, I will immediately return it to the U.S. Department of State. The address is provided on page 2 of this form.

Signature

Date (mm-dd-yyyy)

PASSPORT OFFICE USE ONLY
Was the passport mailed to the correct mailing address?
Did the vendor (i.e. USPS, FedEx) confirm the delivery?

Yes

No

Yes

No
Date Issued (mm-dd-yyyy)

Previous U.S. Passport Book Number
Place Issued

Date Mailed (mm-dd-yyyy)

Date Issued (mm-dd-yyyy)

Previous U.S. Passport Card Number
Place Issued
DS-86
xx-xxxx

Special Postage, If Used

Date Mailed (mm-dd-yyyy)

Special Postage, If Used
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If the original passport is subsequently received after a replacement
passport has been issued, send the original passport to the following address:
U.S. Department of State
Passport Services
Consular Lost/Stolen Passport Section
Attn: CLASP
1111 19th Street, NW, Suite 500
Washington, DC 20036

DO NOT USE THIS ADDRESS FOR ANY PASSPORT RELATED SERVICE
OTHER THAN THAT DESCRIBED ABOVE.
For More Information Call: 202-955-0430
or
Visit our Website: www.travel.state.gov
WARNING
False statements made knowingly and willfully in passport applications or in affidavits or other supporting documents
submitted therewith are punishable by fine and/or imprisonment under 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 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 AND PAPERWORK REDUCTION ACT STATEMENTS
AUTHORITIES: Collection of the information solicited on this form is authorized by 22 U.S.C. 211a, et seq.; Executive
Order 11295 (August 5, 1966); and Part 51, Title 22, Code of Federal Regulations (CFR), in particular 22 CFR 51.2(b).
PURPOSE: The primary purpose for soliciting the information is to ensure that no person shall bear more than one
valid or potentially valid U.S. passport book and one valid passport card at any one time, except as authorized by the
U.S. Department of State, as well as to combat passport fraud and misuse.
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 adjudicating passport applications and requests for related services,
and for law enforcement and administrative purposes. The information may be made available 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 further 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. citizen '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 (State-05) and Passport Records (State-26) published in
the Federal Register.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Failure to provide the information requested on this
form may result in the refusal to issue a replacement passport.
*Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time
required for searching existing data sources, gathering the necessary data, providing the information required, and
reviewing the final collection. You do not have to provide the information unless this collection displays a currently valid
OMB number. Send comments on the accuracy of this estimate of burden and recommendations for reducing it to:
U.S. Department of State (A/ISS/DIR), Washington, DC 20520.
DS-86

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