DS-64 Lost or Stolen Passport Book or Card - Pilot Screenshots

Passport and Visa Pages Application System

Page 1 of 1

Need help with this Site?
OMB CONTROL NO. 1405-0014
OMB EXPIRATION DATE: 8/31/2015
ESTIMATED BURDEN: 10 Minutes

Privacy Act and Paperwork Reduction Act statements

I have read the Privacy Act and Paperwork Reduction Act statements.

About the Applicant
First Name:

Middle Name:

JOHN

JAMES

Last Name:

Suffix:

SMITH

Date Of Birth (MM/DD/YYYY):

City Of Birth:

11/18/1957

BETHESDA

Country Of Birth:

State/Territory Of Birth:

UNITED STATES

MI - MICHIGAN

Social Security Number:
123-45-6789

Height:

Sex:
Male

Female

Hair Color:
BLACK

Feet: 5

Inches: 11

Eye Color:
GREEN

Occupation:

Employer or School:

PROFESSOR

UNIV OF MD

Populate Form

For any questions about forms or status, please contact the National Passport Information Center
by email at [email protected]
or by phone: 1-877-487-2778 (TDD/TTY: 1-888-874-7793)
For purely technical issues, such as broken links or error messages, please email:[email protected]

http://caedepss2k822.ca.state.sbu:8010/FraudAbuseNotice.aspx

7/27/2015

Passport and Visa Pages Application System

Page 1 of 2

Need help with this Site?

Contact Information
Street Address/RFD#, P.O. Box, or URB:
1234 SALISBURY AVE
Street Address 2
(apartment, company, suite, unit, building or floor if applicable):
#24
Country:

City:

UNITED STATES

COLLEGE PARK
State:

Zip Code:

MD - MARYLAND

20742

In Care Of (e.g. In Care Of - Jane Doe):

Is This Your Permanent Address?
Yes

No

Preferred Method of Communication
Preferred Method of Communication
Mail

Email

Both

Your Email Address
Email Address:
[email protected]

Confirm Email Address:
[email protected]

Your Phone Number 
Phone Number

Type:

Home

Submit Query

(no dashes):
3015555555
Submit Query

http://caedepss2k822.ca.state.sbu:8010/FraudAbuseNotice.aspx

7/27/2015

Passport and Visa Pages Application System

Page 1 of 1

Need help with this Site?

Your Most Recent Passport
Have you been issued any of the following?

Passport Book

Passport Card

Both

Passport Book

Passport Card

Do you still have the book in your possession?

Do you still have the card in your possession?

Yes

No, it was Lost

Yes

Yes, but it was

No, it has been

Yes, but it was

Damaged or Mutilated

Stolen

No, it was Lost

Damaged or Mutilated

NOTE! By selecting Yes

NOTE! By selecting Yes

your application.

your application.

you will be required to
submit your book with

you will be required to
submit your card with

Have you reported your lost or stolen book?
Yes

No, it has been
Stolen

Have you reported your lost or stolen card?

No

Yes

No

The date your most recent passport book was issued

The date your most recent passport card was issued

07/27/2014

07/27/2014

Your name as printed on your most recent book:

Your name as printed on your most recent card:

First and Middle Name:

First and Middle Name:

(MM/DD/YYYY):

(MM/DD/YYYY):

SCOTT

LOGAN

Last Name:

Last Name:

MITCHELL

KELLER

Book number:

Card number:

111111111

B11111111

Fill Debug Values

For any questions about forms or status, please contact the National Passport Information Center
by email at [email protected]
or by phone: 1-877-487-2778 (TDD/TTY: 1-888-874-7793)
For purely technical issues, such as broken links or error messages, please email:[email protected]

http://caedepss2k822.ca.state.sbu:8010/FraudAbuseNotice.aspx

7/27/2015

Passport and Visa Pages Application System

Page 1 of 2

Need help with this Site?

Lost Or Stolen Passport Information

MINORS - If you are reporting a lost or stolen passport for a minor (persons under the age of 16), a parent or guardian must sign and mail-in a paper DS-64
Statement Regarding Lost or Stolen Passport.

Are you reporting your own lost or stolen passport? If you are not reporting your own passport as lost or stolen, you will NOT
be able to submit a report online. However, you will be able to print a completed DS-64 Statement Regarding Lost or Stolen
Passport. The passport holder must carefully review the printed instructions, sign it, submit a photocopy of a governmentissued photo identification (such as a driver’s license or a state-issued identification card), AND mail it to the address
provided on the form.

Yes

No

Did you lose your book and card at the same time and place?

Yes

No

Explain how the book was lost or stolen.

FELL THROUGH THE CRACKS

115

Explain where the lost or theft occurred. Provide Address if known (City/State)

TRAIN STATION

115

On what date was the book lost or stolen (MM/DD/YYYY)? If unknown, when was the last time you remember it in
your possession?
06/27/2015

Explain how the card was lost or stolen.

LEFT IT ON THE BUS

115

Explain where the lost or theft occurred. Provide Address if known (City/State)

BUS STATION

115

On what date was your card lost or stolen (MM/DD/YYYY)? If unknown, when was the last time you remember it in
your possession?
05/27/2015

Have you had other U.S. passport book/card lost or stolen?

Yes

No

How many times? What were the dates?

1 TIME - 01/01/2002

Did you file a police report?

Yes

No

Are you submitting this form in connection with an application for a new U.S. passport?

Yes

No

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 19 U.S.C. 1543. The use

http://caedepss2k822.ca.state.sbu:8010/FraudAbuseNotice.aspx

7/27/2015

Passport and Visa Pages Application System

Page 2 of 2

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.

Fill Debug Values

For any questions about forms or status, please contact the National Passport Information Center
by email at [email protected]
or by phone: 1-877-487-2778 (TDD/TTY: 1-888-874-7793)
For purely technical issues, such as broken links or error messages, please email:[email protected]

http://caedepss2k822.ca.state.sbu:8010/FraudAbuseNotice.aspx

7/27/2015

Passport and Visa Pages Application System

Page 1 of 2

Need help with this Site?

Lost and Stolen Report Review
Review the data below and make edits if needed

Name Provided: JOHN JAMES SMITH
Date Of Birth: 11/18/1957
Place Of Birth: BETHESDA, MI
Social Security Number: 123-45-6789
Sex: Male
Height: 5FT. 11IN.
Hair Color: BLACK
Eye Color: GREEN
Occupation: PROFESSOR
Employer: UNIV OF MD

Mailing Street Address: 1234 SALISBURY AVE
Mailing Street Address 2: #24
City: COLLEGE PARK
Country: USA
State: MD
Zip Code: 20742
In Care Of:

Permanent Address Same As Yes
Mailing Address?:

Email Address: [email protected]
Home Phone: 3015555555

Have Passport Book: Yes

Name On Previous Passport Book: SCOTT MITCHELL
Previous Passport Book Number: 111111111
Book Issuance Date: 07/27/2014
Book Still In Possession: No, it was Lost

Have Passport Card: Yes

Name On Previous Passport Card: LOGAN KELLER
Previous Passport Card Number: B11111111
Card Issuance Date: 07/27/2014

http://caedepss2k822.ca.state.sbu:8010/FraudAbuseNotice.aspx

7/27/2015

Passport and Visa Pages Application System

Page 2 of 2

Card Still In Possession: No, it was Lost

Reporting your own lost or stolen Yes
passport:

On what date was your book lost or 06/27/2015
stolen?:

Explain where the book lost or theft TRAIN STATION
occurred:

Explain how the book was lost or stolen: FELL THROUGH THE CRACKS

On what date was your card lost or 05/27/2015
stolen?:

Explain where the car lost or theft BUS STATION
occurred:

Explain how the card was lost or stolen: LEFT IT ON THE BUS

Had previous U.S. passport lost or stolen: Yes
How many times? What were the dates? 1 TIME - 01/01/2002
Did you file a police report? No

For any questions about forms or status, please contact the National Passport Information Center
by email at [email protected]
or by phone: 1-877-487-2778 (TDD/TTY: 1-888-874-7793)
For purely technical issues, such as broken links or error messages, please email:[email protected]

http://caedepss2k822.ca.state.sbu:8010/FraudAbuseNotice.aspx

7/27/2015

Passport and Visa Pages Application System

Page 1 of 2

Need help with this Site?

Electronic Signature
DS 64 E-Signature
How would you like to send your statement regarding a lost or stolen passport?
Sign and Send Online

Print, Sign and Mail

Would you like to receive your reference number via email?
Yes

No

Would you like to receive your acknowledgement letter via email?
Yes

No

Security Questions
What is your full name as it appeared on your lost or stolen passport book or card?
First Name:

Last Name:

KARL

PILKINGTON

What is your social security number?
222-33-4444

What is your mother’s maiden name?
MARY SMITH

What is your place of birth (State if born in the U.S.; Country if born outside of the U.S.)?
Country Of Birth:

State/Territory Of Birth:

USA - United States of America

VA - VIRGINIA

What year was your lost or stolen passport book or card issued?
2014

Who did you list as your emergency contact on your most recent passport application?
KIEU MAI

What is your date of birth?
01-23-1960

Fill Debug Values

For any questions about forms or status, please contact the National Passport Information Center
by email at [email protected]
or by phone: 1-877-487-2778 (TDD/TTY: 1-888-874-7793)
For purely technical issues, such as broken links or error messages, please email:[email protected]

http://caedepss2k822.ca.state.sbu:8010/FraudAbuseNotice.aspx

7/27/2015

Passport and Visa Pages Application System

Page 1 of 1

Need help with this Site?

Signature Review
Please review your answers before continuing.

What is your full name as it appeared on your lost or stolen

KARL PILKINGTON

passport book or card?

What is your social security number?
What is your date of birth?
What is your place of birth (State if born in the U.S.; Country if

222-33-4444
01-23-1960
VA

born outside of the U.S.)?
What is your mother’s maiden name?
Who did you list as your emergency contact on your most recent

MARY SMITH
KIEU MAI

passport application?
What year was your lost or stolen passport book or card issued?

2014

Read the following information carefully before dating, electronically signing, and submitting the report. Your lost or stolen passport report is
now ready to submit. Please note that this does not necessarily mean that your report is complete, as additional information may be needed
after Department of State personnel have reviewed the information. By clicking "Sign and Submit Report" you are electronically signing the
report. By electronically signing this document you are certifying that you have read, and understood the questions set forth in this form and
that the answers you have furnished on this form are true and correct to the best of your knowledge and belief. By clicking "Sign and Submit
Report" you are certifying that you understand any false or misleading statement may result in permanent refusal of a passport. Pursuant to 28
U.S.C. 1746 all declarations made in this application are unsworn declarations made under penalty of perjury.
Do not click "Sign and Submit Report" unless you are willing to certify the above. Once you have clicked "Sign and Submit Report" you will be
unable to make changes to the report. Only click the button below if you have reviewed the information and it is correct.

For any questions about forms or status, please contact the National Passport Information Center
by email at [email protected]
or by phone: 1-877-487-2778 (TDD/TTY: 1-888-874-7793)
For purely technical issues, such as broken links or error messages, please email:[email protected]

http://caedepss2k822.ca.state.sbu:8010/FraudAbuseNotice.aspx

7/27/2015

Passport and Visa Pages Application System

Page 1 of 1

Need help with this Site?

Next Steps
After reading and acknowledging your understanding of the instructions, you will be ready to
submit your Passport form(s).

The report on the lost or stolen passport you are about to file will be placed immediately into our
Consular Lost and Stolen Passport System. This system is designed to prevent the misuse of your
lost or stolen U.S. passport. Anyone using your lost or stolen passport will be detained upon entry
into the United States or may be denied boarding an airplane. If the passport is found at a later time,
it must be reported as found and submitted for cancellation.
AS SOON AS YOU CLICK SUBMIT, THE PASSPORT BEING REPORTED IS INVALIDATED. The passport
CANNOT be used for travel and CANNOT be reinstated or reactivated.
I have read and acknowledge the steps and information contained above.

1. Submit your Online Lost or Stolen
Report

2. Exit and Start New Form

By clicking "Submit" your passport will be

typed in and return you to the beginning of

INVALIDATED and CANNOT be used for travel

the online process so you may complete

or reinstated/reactivated. You will receive an

another form. NOTE: Please be sure to submit

acknowledgement via e-mail and have the

your Lost/Stolen Report before proceeding.

This will delete any information you have

option to print a hardcopy of the Lost or
Stolen Report on the next screen.

* Adobe Acrobat is required

For more information on how and where to apply for a passport, See Get or Renew a Passport.
For any questions about forms or status, please contact the National Passport Information Center
by email at [email protected]
or by phone: 1-877-487-2778 (TDD/TTY: 1-888-874-7793)

For purely technical issues, such as broken links or error messages, please email:[email protected]

http://caedepss2k822.ca.state.sbu:8010/FraudAbuseNotice.aspx

7/27/2015