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APPLICATION FOR A U.S. PASSPORT FOR ELIGIBLE INDIVIDUALS
OMB CONTROL NO.: 1405-0160
EXPIRATION DATE: XX-XX-XXXX
ESTIMATED BURDEN: 40 MIN
CORRECTION, NAME CHANGE TO PASSPORT ISSUED 1 YEAR AGO OR LESS, AND LIMITED PASSPORT REPLACEMENT
For information or questions, visit the official U.S. Department of State website at travel.state.gov or contact the National
Passport Information Center (NPIC) at 1-877-487-2778 (TDD/TTY: 1-888-874-7793) or [email protected].
CAN I USE THIS FORM?
I changed my name, by marriage or court order, less than one year after my most recent U.S. passport
book and/or card was issued and my U.S. passport book and/or card was issued less than one year ago.
Oves
OR
Oves
My identifying information in my most recent U.S. passport book and/or card was printed incorrectly.
OR
Oves
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My most recent U.S. passport book was limited to two years or less for a reason other than multiple
losses or serious damage/mutilation of previous passports.
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If you answered "No" to all three statements above, STOP. You cannot use this form.
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Instead, you must apply on form DS-82 or DS-11 depending on your circumstances.
Passport forms are available at travel.state.gov/passportforms.
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NOTICE TO APPLICANTS RESIDING ABROAD
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United States citizens residing outside the U.S. and Canada cannot submit this form to domestic addresses listed below. Such applicants
should visit usembassy.gov to find the nearest U.S. embassy or consulate for procedures when applying outside the United States.
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IS THERE A FEE WITH THIS APPLICATION?
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There is no fee to use this form unless expedited service is requested for a name change or limited passport replacement (see below). Note: A passport
issued with a data error (e.g., name, gender, or place of birth) or printing error (e.g., data is missing on the biographical page, discoloration, crooked printing,
etc.) is corrected at no cost (with no expedite fee) if the passport is still valid. Your re-issued passport book and/or card and any documentary evidence
submitted to the Department will be returned to you by priority or first class mail, unless overnight delivery is requested. Photocopies will not be returned.
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Enclose expedited service fee(s) 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. Visit travel.state.gov/passportfees for current fees.
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Do not send cash. The Department cannot be responsible for cash sent through the mail.
WHERE DO I MAIL THIS APPLICATION?
The Department recommends using trackable mailing service when submitting your application.
1. Complete, sign, and date this form.
2. Send this form with your most recent U.S. passport book and/or card, a new color photograph (taken within the last six months), and
any required additional documents.
FOR ROUTINE SERVICE (No fee required):
National Passport Processing Center
Post Office Box 90107
Philadelphia, PA 19190-0107
FOR EXPEDITED SERVICE (Fee required, see below):
National Passport Processing Center
Post Office Box 90907
Philadelphia, PA 19190-0907
Expedited Service: Available for a fee. Our website travel.state.gov contains updated information regarding fees and processing times for expedited
service. Expedited service is only available for passports mailed in the United States and Canada. Please write "Expedite" on the outer envelope when
mailing.
1-2 Day Delivery: Available for a fee. This service is only available for passport books (and not passport cards) mailed within the United States.
NOTE: To ensure minimal processing time for expedited applications, the Department recommends using 1-2 day delivery service to submit the
application and to include the appropriate postage fee for 1-2 day return delivery for the newly issued passport book. Please visit travel.state.gov for
updated information regarding fees, processing times, or to check the status of your passport application on line.
If you choose to provide your email address in item #6 on page 1 of the application, the Department may use that information to contact you in the event
there is a problem with your application or if additional information is required.
D5-5504 XX-XXXX
Instruction Page 1 of 4
WHAT TO SUBMIT WITH THIS APPLICATION
Please print page one and page two of your application on separate pieces of paper. You do not need to submit instruction pages.
• Your most recent U.S. passport book and/or card;
• A new color photograph (taken within the last six months); and
• Any additional required documents.
1. A NEW COLOR PHOTOGRAPH
Submit one color photograph, 2x2 inches in size. Photographs must meet the following requirements:
• Head must be 1-1 3/8 inches from the bottom of the chin to the top of the head
• High resolution photo that is not blurry, grainy, or pixelated
• Taken less than six months ago
• No glasses or hat/head covering*
• Use a plain white or off-white background
• Head must face the camera directly with full face in view
• Printed on matte or glossy photo quality paper
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(See the full list on travel.state.gov/photos)
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*Head coverings are not acceptable unless you submit a signed statement verifying that it is part of recognized, traditional
religious attire that is customarily or required to be worn continuously in public, or a signed doctor's statement verifying its daily
use for medical purposes. Glasses or other eyewear are not acceptable unless you submit a signed statement from a doctor
explaining why you cannot remove them (e.g., during the recovery period from eye surgery).
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USE CAUTION WHEN STAPLING YOUR PHOTO:
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Use 4 staples vertically in the corners as close to the outer edges as possible. Do not bend the photo.
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2. ADDITIONAL DOCUMENTS
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NAME CHANGE:
• If your name has changed less than one year after your U.S. passport book and/or card was issued and your U.S. passport
book and/or card was issued less than one year ago, you may use this form.
CORRECTION:
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• You must submit a certified name change document such as a certified copy of your marriage certificate or a certified copy of
a court order showing a seal and officiate/judge's signature. If you are unable to document your name change in this manner,
you must apply on form DS-11, Application for a U.S. Passport.
• If there is an error in your recently issued, valid U.S. passport book and/or card, you must submit the appropriate document
showing the correct information (e.g., certified birth certificate or certified marriage certificate as described above.)
LIMITED PASSPORT REPLACEMENT:
• If you are re-applying because your U.S. passport book was limited in validity due to insufficient evidence of U.S.
citizenship and/or identity, you must submit evidence of your U.S. citizenship (such as a government-issued birth
certificate or a U.S. Certificate of Naturalization) and/or evidence of your identity (such as a driver's license or a
state-issued identification card). You must establish your citizenship and identity to the satisfaction of the Department of
State. We may ask you to provide additional evidence to support your claim to U.S. citizenship and/or to establish your
identity. Please refer to the letter included with your passport for instructions.
• If your U.S. passport book was limited due to gender transition, please visit travel.state.gov for more information.
• Passport books limited in validity due to serious damage or multiple losses cannot be extended. Please contact
the NPIC or visit travel.state.gov for more information.
• All documentary evidence that is not damaged, altered, or forged will be returned to you. Photocopies will not be
returned.
DS-5504XX-XXXX
Instruction Page 2 of 4
GENDER MARKER INFORMATION
We print passport holders’ gender in the "Sex" field of U.S passports. The gender markers we use are: M (male), F (female) and X
(unspecified or another gender identify). The gender marker that you check on this form will appear in your passport regardless of the gender
marker(s) on your previous passport and/or your supporting evidence of citizenship and identity. If changing your gender marker select "Yes"
in the "Gender" section (item #3) on Application Page 1. If no gender marker is selected, we will print the gender as listed on your supporting
evidence. Please Note: We cannot guarantee that other countries you visit or travel through will accept the gender marker on your
passport. Research the laws of the countries you plan to visit or travel through to make sure you understand their entry requirements. Some
countries and travel companies may not recognize the "X" gender marker. Visit travel.state.gov for more information.
INFORMATION ON HOW YOU RECEIVE YOUR PASSPORT(S)
Separate mailings: You may receive your newly issued U.S. passport book and/or card and your documentary evidence in two separate
mailings. If you are applying for both a U.S. passport book and card, you may receive three separate mailings: one with your documentary
evidence; one with your newly issued U.S. passport book, and one with your newly issued U.S. passport card. Photocopies will not be
returned.
Passport numbers: Each newly issued passport book and/or card will have a different passport number than your previous one.
"In Care Of": If you do not live at the address listed in the "Mailing Address" section (item #8) Application Page 1, put the name of the person
who does live at that address and write "In Care Of" "Mailing Address Line 2". If the applicant is a minor child, you must include the "In
Care of" name of the adult registered to receive mail at this address.
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Moved? If your mailing address changes prior to receipt of your new passport, please contact the NPIC at 1-877-487-2778
(TDD/TTY:1-888-874-7793) or [email protected].
NOTE: The U.S. Department of State will not mail a U.S. passport book and/or card to a private address outside the United States or Canada.
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WHAT IS THE DIFFERENCE BETWEEN A PASSPORT BOOK AND A PASSPORT CARD?
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The U.S. passport card is not valid for international air travel. Unlike the U.S. passport book, the U.S. passport card is valid only
for entry at land border crossings and sea ports of entry when traveling from Canada, Mexico, Bermuda, and the Caribbean.
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The maximum number of letters provided for your given name (first and middle) on the U.S. passport card is 24 characters. If both
your given names are more than 24 characters, you must shorten one of the given names you list on item #1 on page 1of 2.
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Both the U.S. passport book and card are U.S. passports. They reflect the bearer's identity and nationality, and they are subject to
existing passport laws and regulations. U.S. passports are only issued to U.S. citizens or non-citizen U.S. nationals.
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HOW FEES ARE ESTABLISHED AND PROCESSED
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Passport service fees are established by law and regulation (see 22 U.S.C. 214, 22 C.F.R 22.1, and 22 C.F.R. 51.50-56), and are collected at the
time you apply for the passport service.
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If we fail to receive full payment of the applicable fees (for example, if your check is returned for any reason or you dispute a passport fee charge to
your credit card), the U.S. Department of State will take action to collect the delinquent fees from you under 22 C.F.R. Part 34 and the Federal Claims
Collection Standards (see 31 C.F.R. 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, we will refer the debt to the U.S. Department of the Treasury for collection.
Debt collection procedures used by the U.S. Department of the Treasury may include referral of the debt to private collection agencies, reporting of
the debt to credit bureaus, garnishment of private wages, and administrative offset of the debt by reducing, or withholding eligible federal payments
(e.g., tax refunds, Social Security payments, federal retirement, etc.) by the amount of your debt, including any interest penalties or other costs
incurred. In addition, non-payment of passport fees may result in the invalidation of your passport. An invalidated passport cannot be used for travel.
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 check. The debit from your account will usually occur within 24 hours and
will be shown on your regular account statement. 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 original check. If the EFT
cannot be completed because of insufficient funds, we may try to make the transfer up to two times, and we will charge you a one-time, nonrefundable fee of $25, which we will also collect by EFT.
NOTICE TO APPLICANTS FOR NO-FEE REGULAR, SERVICE, OFFICIAL, OR DIPLOMATIC PASSPORTS
You may use this application if you meet all of the provisions listed; 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.
PROTECT YOURSELF AGAINST IDENTITY THEFT - REPORT YOUR PASSPORT LOST OR STOLEN
A United States citizen or non-citizen national may not normally have more than one valid or potentially valid U.S. passport book or more than one valid or
potentially valid U.S. passport card at a time. Therefore, when a valid or potentially valid U.S. passport book or card cannot be presented with a new
application, you must submit form DS-64, Statement Regarding a Lost or Stolen Valid U.S. Passport. Your statement must detail why the previous U.S.
passport book or card cannot be presented.
The information you provide regarding your lost or stolen U.S. passport book or card 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 book or card. Anyone using the U.S. passport book or card that was reported lost
or stolen may be detained upon entry into the United States. If you find the U.S. passport book or card that was reported lost or stolen, immediately
report it as found and submit it for cancellation. It has been invalidated. You may not use that U.S. passport book or card for travel.
For more information about how to report a lost or stolen U.S. passport book or card, please call the NPIC at 1-877-487-2778 (TDD/TTY: 1-888-87 4-7793) or
visit travel.state.gov/loststolen.
DS-5504 XX-XXXX
Instruction Page 3 of 4
WARNING
False statements made knowingly and willfully in passport applications, including affidavits or other documents submitted to support this
application, are punishable by fine and/or imprisonment under U.S. law including the 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 imprisonment under the
provisions of 18 U.S.C. 1543. The use of a passport in violation of the restrictions contained herein or of the passport regulations is punishable
by fine and/or imprisonment under 18 U.S.C. 1544. All statements and documents are subject to verification.
Failure to provide information requested on this form, including your Social Security number, may result in significant
processing delays and/or the denial of your application.
FEDERAL TAX LAW
Section 6039E of the Internal Revenue Code (26 U.S.C. 6039E) and 22 U.S.C. 2714a(f) require you to provide your Social Security number
(SSN), if you have one, when you apply for or renew a U.S. passport. If you have never been issued an SSN, enter zeros in item #5 on page 1
of this form. If you are residing abroad, you must also provide the name of the foreign country in which you are residing. The U.S. Department
of State must provide your SSN and foreign residence information to the U.S. Department of the Treasury. If you fail to provide the information,
your application may be denied, and you are subject to a $500 penalty enforced by the Internal Revenue Service (IRS). All questions on this
matter should be directed to the nearest IRS office.
ACTS OR CONDITIONS
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Your Social Security number will be provided to the U.S. Department of the Treasury, and may be used in connection with debt collection and
checked against lists of persons ineligible or potentially ineligible to receive a U.S. passport, among other authorized uses.
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If any of the below-mentioned acts or conditions have been performed by or apply to the applicant, a supplementary explanatory statement
under oath (or affirmation) by the applicant should be attached and made a part of this application.
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I have not been convicted of a federal or state drug offense or convicted of a "sex tourism" crimes statute, and I am not the subject of an
outstanding federal, state, or local warrant of arrest for a felony; a criminal court order forbidding my departure from the United States; or a
subpoena received from the United States in a matter involving federal prosecution for, or grand jury investigation of, a felony.
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PRIVACY ACT STATEMENT
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AUTHORITIES: Collection of this information is authorized by 22 U.S.C. 211 a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E, 22 U.S.C. 2714a(f),
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 C.F.R. parts 50 and 51.
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PURPOSE: We are requesting this information in order to determine your eligibility to be issued a U.S. passport. Your Social Security number
is used to verify your identity.
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ROUTINE 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. These routine uses include, but are not
limited to, law enforcement activities, employment verification, fraud prevention, border security, counterterrorism, litigation activities, and
activities that meet the Secretary of State's responsibility to protect U.S. citizens and non-citizen nationals abroad. Your Social Security number
will be provided to the U.S. Department of the Treasury and may be used in connection with debt collection, among other purposes authorized
and generally described in this section. More information on the routine uses for the system can be found in System of Records Notices StateOS, Overseas Citizens Services Records and Other Overseas Records and State-26, Passport Records.
DISCLOSURE: Providing information on this form is voluntary. Be advised, however, that failure to provide the information requested on this
form may cause delays in processing your U.S. passport application and/or could also result in the refusal or denial of your application. Failure
to provide your Social Security number may result in the denial of your application (consistent with 22 U.S.C. 2714a(f)) and may subject you to
penalty enforced by the Internal Revenue Service, as described in the Federal Tax Law section of the instructions to this form.
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 40 minutes per response, including the time required for
searching existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final
collection. You do not have to supply this information unless this collection displays a currently valid 0MB control number. If you have comments on
the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: Passport Forms Officer, U.S.
Department of State, Office of Program Management and Operational Support, 44132 Mercure Cir, PO Box 1199, Sterling, Virginia, 20166-1199.
DS-5504 XX-XXXX
Instruction Page 4 of 4
U.S. Department of State
APPLICATION FOR A U.S. PASSPORT FOR ELIGIBLE INDIVIDUALS
OMB CONTROL NO.: 1405-0160
EXPIRATION DATE: XX-XX-XXXX
ESTIMATED BURDEN: 40 MIN
CORRE CTION, NAME CHANGE TO PASSPORT ISSUE D 1 YEAR AGO OR LE SS, AND LIMITED PASSPORT REPLACEMENT
Gender (Read Instruction Page 3) 4. Place of Birth (City & State if in the U.S. or City & Country as it is presently known.)
F X Changing gender marker?
Yes
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1 3/8”
FROM 1” TO
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YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW
THEN COMPLETE PAGE 2
I declare under penalty of perjury all of the following: 1) I am a citizen or non-citizen national of the United States and have not performed any of the acts listed under "Acts or
Conditions" on page four of the instructions of this application (unless explanatory statement is attached); 2) the statements made on the application are true and correct; 3) I
have not knowingly and willfully made false statements or included false documents in support of this application; 4) the photograph submitted with this application is a
genuine, current photograph of me; and 5) I have read and understood the warning on page of the instructions to the application form.
DS 5504 C 03 2022 1
DS-5504 XX-XXXX
Name of Appl leant (Last, First & Middle)
11. Height
Date of Birth (nm'ddlyyyy)
13. Eye Color
12. Hair Color
15. Employer or School (if applicable)
14. Occupation (if age 16 orolder')
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16. Addltlonal Contact Phone Numbers
Home
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Cel
WOii(
Home
Cell
WOii(
17. Permanent Address: (Complete if PO Box is listed in Mailing Address Jl£ If residence is different from Mailing Acl:Jress. Do not list a PO Box.)
Street/RFD# or URB
Apartment/Unit
City
State
Zip Code
18. Your Emergency Contact (Provide the information of a person not traveling with you to be contacted in the event of an emergency.)
Address: Street/RFD# or PO Box
Name
Apartment/Unit
State
Zip Code
Phone Number
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Relationship to Applica,t
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19. Travel Plans (N no travel plans, please write "none'7
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City
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Departure Date (mmlddlyyw) Return Date (mmt1dlyyyy) Countries to be visited
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First
I
Middle
____________
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No
Yes
21. If )'BS, � your submitted passport book
andlor card Is less than one year old, please
oomplete this section with your new name.
Name Last
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20. Has your name changed by marriage or
court order less than one year after your U.S.
passport book andlor card was Issued?
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Please complete the following questions
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Note: You must submit evidence documenting your name change (such as a certified marriage certificate or a certified oourt order) and your current U.S.
passport book and/or card, along with this oompleted form to the address listed on instruction page 1.
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If you cannot or did not meet the above criteria, please oomplete form DS-82, U.S. Passport Renewal Application for Eligible Individuals or form
DS-11, Application for a U.S. Passport.
22. Was your Identifying lnformation printed
Incorrectly In your U.S. passport
book andlor card?
Yes
Name Last
First
I
No
If )'BS, only check the box(es) next to the
fleld(s) that need to be corrected and
oomplete the information as it should appear.
Date of Birth (mm/ddlyyyy)
Gender
M F X
I
Middle
Place of Birth (State or Co111try)
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Note: Please submit evidence documenting your correct identifying information (such as a certified marriage certificate or birth
certificate) and your current U.S. passport book and/or card, along with this completed form to the address listed on Instruction
Page 1. Visit travel.state.gov for information on gender markers.
23. Was your most recent U.S. passport book limited for
two years or less?
Note: To complete a limited U.S. passport book replacement, your
submitted U.S. passport book must not be expired. Passport books
limited in validity because of multiple losses, damages, or mutilations
cannot be extended.
No
Yes
Please be sure to enclose your U.S. passport book along with this
application to the address listed on Instruction Page 1.
If yes, please submit evidence of your U.S. citizenship
(such as U.S. birth certificate or naturalization certificate)
and/or evidence of your identity (such as a driver's license
or state-issued ID card).
DS 5504 C 03 2022 2
DS-5504 XX-XXXX
Page 2 of 2
| File Type | application/pdf |
| File Modified | 2022-02-17 |
| File Created | 2021-03-24 |