US. Department of State ‘OMB Control No. 1405-0004 Expiration Date: 04-30-2025 APPLICATION FOR A U.S. PASSPORT Eserneies Burien 'ac bance Please read all instructions first and type or print in black ink to complete this form. For information or questions, visit travel.state.gov or contact the National Passport Information Center (NPIC) at 4-877-487-2778 (TOD/TTY: 1-888-874-7793) or [email protected]. ‘SECTION A. ELIGIBILITY TO USE THIS FORM This form is used to apply for a U.S. passport book and/or card in person at an acceptance facility, a passport agency (by appointment only), or a U.S, embassy, consulate, or consular agency (if abroad). The U.S. passport is a travel document attesting to one's identity and. issued to U.S. citizens or non-citizen U.S. nationals. To be eligible to use this form you must apply in person if at least one of the following is true: ¥_ 1am applying for my first U.S. passport ‘My previous U.S. passport was either: a) issued under age 16; 'b)igau0d moro than 16. ‘+ Notice to Applicants Under Age 16: You must appear in person to apply for a U.S. passport with your parent(s) or legal guardians). ‘See Section D of these instructions or travel state.gov for more details. ‘+ Notice to Applicants Ages 16 and 17: At least one of your parent(s) or legal guardian(s) must know that you are applying for a U.S. passport, See Section D of these instructions or travel.state. gov for more details + Notice to Applicants for No-Fee Regular, Service, Official, or Diplomatic Passports: You may use this application if you meet all 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 and forwarded to you. SECTION B. STEPS TO APPLY FOR A U.S. PASSPORT ‘Complete this form (Do not sign until requested to do so by an authorized agent) ‘Attach one color photograph 2x2 inches in size and supporting documents (See Section D of these instructions. ‘Schedule appoinimant to annly in person by visiting our website or caling NPIC. (see contact info at the ton nage). Arrive for appointment and present completed form and attachments to the authorized agent who will administer the oath, witness you signing your form, and collect your passport fee. ‘Track application status online at Passportstatus.state.gov. Receive new passport and original supporting documents (that you submitted with your application) ‘SECTION C. HOW TO COMPLETE THIS FORM Please see the instructions below for items on the form that are not self-explanatory, The numbers match the numbered items ofthe form. 1. Name (Last, First, Middle): Enter the name to appear in the passport. The name to appear in the passport should be consistent with your proof of citizenship and identification. If you have changed your name and are not eligible to use a DS-82 or DS-5504, you must Use this form. Visit travel.state.govinamechange for more information 2._ Date of Birth: Use the following format: Month, Date, and Year (MM/DDIYYYY). 3. Gender: The gender markers used are “M" (male), °F" (female) and "X" (unspecified or another gender identity). 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 from what was printed on your previous passport, select "Yes" inthis field on Application Page 1. f no gender marker is selected, we may print the gender as listed on your supporting evidence or contact you for more information. Please Note: We cannot guarantee that other countries you visitor travel through will recognize the gender marker on your passport. Visit travel state govigender for more information. ‘4. Place of Birth: Enter the name of the city and state ifn the U.S. or city and country as presently known. 5. Social Security Number: You must provide a Social Security number (SSN), if you have been issued one, in accordance with Section 6039E of the Internal Revenue Code (26 U.S.C. 6039E) and 22 U.S.C 2714a(f. If you do not have a Social Security number, you must enter zeros in tis field and submit a statement, signed, and dated, that includes the phrase, */ deciare under penalty of perury under the laws of the United States of America that the following is true and correct: | have never been issued a Social Security Number by the Social Security Administration” If you reside abroad, you must also provide the name of the foreign country where you reside. The US. Department of State must provide your SSN and foreign residence information to the U.S. Department of the Treasury which will Use it in connection with debt collection and check against lists of persons ineligible or potentially ineligible to receive a U.S. passport, ‘among other authorized uses. If you fail to provide the information, we may deny your application and the Intemal Revenue Service IRS) may enforce a penalty. Refer all questions on this matter to the nearest IRS office. 6. Email: By providing your email you are consenting tous | 7. Primary Contact Phone Number: If providing a mobiee/cell communicating with you by email about your application phone number you are consenting to receive calls andior text messaging about your application. ‘8. Mailing Address Line 1 and 2 "In Gare OF For ine 1 enter applicant's StreeRFO #, or P.O. Box or URB. For ine 2, if you do not Ive al the address istd in tis fel, put the name of the person who ives at this address and markt"n Gare OF. Ifthe applicant is a minor child, you must include the “In Care Of" name of the parent or adult registered to receive mail at this address. 9. List all other names you have used: Enter all legal names previously used to include maiden name, name changes, and previous married names. You can enter up to two names one in item A and one in item B. If only your last name has changed just enter your last name. ityou need more space to write additional names, please use a s er and attach ito this form. Biue Section Application Page 1 - kdentifying Documents and Signature Blocks: Skip this section and complete Application Page 2 n until requested to do so by the authorized agent who will admi DS-11 04-2022 Instruction Page 1 of 4USS. Department of State APPLICATION FOR A U.S. PASSPORT 1. PROOF OF U.S. CITIZENSHIP Information can be found on travel.state.govlctizenship. Applicants Born in the United States ‘Your evidence will be returned to you if it is not damaged, altered, ( forged. Submit an original or certified copy and a photocopy of the front and back if there is printed information on the back, of, Applicants Born Outside the United States. Ifwe determine that you are a U.S. citizen, your lawful permanent resident card submitted with this application will be forwarded to USS. Citizenship and Immigration Services. ‘one of the following documents: * Claiming Citizenship through Naturalization of One or Both * US. Birth Certificate that meets all the following requirements: Parent(s), submit all the following: ‘© Issued by the city, county, or state of birth © Your parent(s) Certificates) of Naturalization © Lists your full name, birthdate, and birthplace ° © Lists your parent(s} full names © Lists date filed with registrar's office (must be within one ‘Your parents’ marriage/certifcate and/or evidence that you were in the legal and physical custody of your U.S. citizen Parent, if applicable year of birth) © Your foreign birth certificate (and official translation ifthe ‘© Shows registrars signature and the seal of the issuing document is not in English) authority ‘© Your evidence of admission to the United States for legal Eully valid, undamaged U.S. passport (may be expired Consular Report of Birth Abroad or Certification of Birth Abroad Certificate of Naturalization or Citizenship Permanent residence and proof you subsequently resided in the United States * Claiming Citizenship through Birth Abroad to At Least One U.S. Gitzen Parent, submit all the folowing: “Yuur Corsuler Repurl uf Bill Abra (Fuss F9-240), Certification of Birth (Form DS-1350 or FS-545), or your foreign birth certificate (and official translation if the document is not in English) ‘+ Secondary documents may be submitted if the U.S. birth Certiticate was fied more than one year after your birth or it no birth record exists. For no birth record on file, submit a registrar's letter to that effect. For both scenarios, submit a combination of the evidence listed below, with your first and last name, birthdate and/or birthplace, the seal or other certification ‘© Your parent's proof of U.S. citizenship of the office (customary), and the signature of he issuing © Your parents’ mariage certificate _ official &-_Afdavit showing al your U.S. ctizen parents’ periods and places of residence and physical presence before your ‘A hospital birth record birth (DS-5507) © Anearly baptismal or circumcision certificate © Early census, school, medical, or family Bible records (© Insurance files or published birth announcements (such as_| * ‘a newspaper article) © Notarized affidavits (or DS-10, Birth Alfidavit) of older blood relatives having knowledge of your birth may be submitted © Your permanent residence status in addition to some of the records listed above. Your full and final adoption ‘© You were in the legal and physical custody of your U.S. citizen parent(s) © _You have resided in the United States Clsiming Citizenship Through Adoption by a U.S. Citizen Parent(s), if your birthdate is on or after October 5, 1978, ‘Submit evidence of all the following: 2, PROOF OF IDENTITY Information can be found at travel state.gov/identiication, Present your original identification and submit a front and back photocopy with this form. It must show a photograph that is a good likeness of you. Examples include: ‘+ Drivers license (not temporary or learner's permit) s ‘+ Previous or current U.S. passport bookicard . + _ Military identification Federal, state, or city government employee identification Cerificate of Naturalization or Citizenship 3. ARECENT COLOR PHOTOGRAPH See the ful list of photo requirements on travel.state goviphotos. ‘Attach one photo, 2x2 inches in size. U.S. passport photo requirements may differ from photo requirements of other countries. To avoid processing delays, be sure your photo meets all the following requirements (Refer to the photo template on Application Page 1) ‘+ Taken less than six months ago + No eyeglasses and head covering and no uniforms" ‘+ Head must be 1-1 3/8 inches from the bottom of the ‘+ Printed on matte or glossy photo quality paper chin to the top of the head ‘+ Use a plain white or off-white background ‘+ Head must face the camera directly with full face in view “Head coverings are not acceptable unless you submit a signed statement verifying that itis part of recognized, traditional religious attire that is customarily or required to be wor continuously in public or a signed doctors 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). Photos are to be taken in clothing normally worn on a daily basis. You cannot wear a Uniform, clothing that looks like a uniform, or camouflage attire. DS-11 04-2022 Instruction Page 2 of 4US. Department of State ae APPLICATION FOR A U.S. PASSPORT PROOF OF PARENTAL RELATIONSHIP (FOR APPLICANTS UNDER AGE 16) Parents/guardians must appear in person with the child and submit the following: ‘+ Evidence of the child's relationship to parents/guardian(s) (Example: a birth certificate or Consular Report of Birth Abroad listing the names of the parent(s\/guardian(s) and child) ‘* Original parenta/guardian government-issued photo identification and a photocopy of the front and back (to salisfy proof of identity) Ionly one parent/guardian can appear in person with the child, you must also submit one of the following: ‘+The second parent's notarized written statement or DS-3053 (including the child's full name and date of birth) consenting to the passport issuance for the child. The notarized statement cannot be more than three months old, must be signed and notarized on the same day, and must come with a front and back photocopy of the second parent's government-issued photo identification The secorid parent's dealt verilcate (I second parent Is deceased) Evidence of sole authority to apply (Example: a court order granting sole legal custody or a birth certificate listing only one parent) A written statement (made under penalty of perjury) or DS-5525 explaining, in detail, why the second parent cannot be reached ooo PROOF OF PARENTAL AWARENESS (FOR APPLICANTS AGES 16 AND 17) We may request the consent of one legal parent/legal guardian to issue a U.S. passport to you. In many cases, the passport authorizing officer may be able to ascertain parental awareness of the application by virtue of the parent's presence when the minor submits the pplication or a signed note from the parent or proof the parent is paying the application fees. However, the passport authorizing officer retains discretion to request the legal parent's/legal guardian's notarized statement of consent to issuance (e.9., on Form DS-3053). 5. FEES Passport service fees are established by law and regulation (see 22 USC. 214, 22 CFR. 22.1, and 22 CFR. 51.50-66) and are collected at the time you apply for the passport service. By law, the passport fees are non-refundable. Visit travel.state.gov! assportfees for current fees and how fees are used and processed. Payment methods are as follows: Applicant Applying in the United States Applicant Applying at a Passport Agency or ‘At Acceptance Facility ‘Outside the United States ‘+ Passport fees must be made by check (personal, certified, © We accept checks (personal, certified, cashier's, travelers); cashiers, travelers) or money order (U.S. Postal, international, major credit cards (Visa, Master Card, American Express, currency exchange) with the applicant's full name and date of Discover); money orders (U.S. Postal, international, currency birth printed on the front and payable to "U.S. Department of ‘exchange); or exact cash (no change provided). Make all fees State." payable to the "U.S. Department of State.” ‘+ The execution fee must be paid separately and made payable | « If applying outside the United States: Please see the website of to the acceptance facility in the form that they accept. your embassy, consulate, or consular agency for acceptable payment methods. ‘Other Services Requiring Additional Fee (Visit travel state.gov for more deta + Expedite Service: Only available for passports mailed in the United States and Canada. + 4-2 Day Delivery: Only available for passport book (and not passport card) mailings in the United States ‘+ Verification of a previous U.S. Passport or Consular Report of Birth Abroad: Upon your request, we verify previously issued U.S. passport or Consular Report of Birth Abroad if you are unable to submit evidence of US. citizenship. Special Issuance Passports: Ifyou apply fora no-fee regular, service, offical, or diplomatic passport at a designated acceptance ‘act. you must pay the execution fee. No other fees are charged when you appl |Submitting your form depends on your location and how soon you need your passport. \* Applicant Located Inside the United States: For the latest information regarding processing times, scheduling appointments, and nearest designated acceptance facilities vist travel.state. gov or contact NPIC. \* Applicant Located Outside the United States: In most countries, you must apply in person at a U.S. embassy or consulate for all passport services. Each U.S. embassy and consulate has different procedures for submitting and processing your application. Visit travel.state.gov to check the U.S. embassy or consulate webpage for more information. '* Difference Between U.S. Passport Book and Card: The book is valid for international travel by air, land, and sea. The card is not valid for international air travel, only for entry at land border crossings and seaports of entry when traveling from Canada, Mexico, Bermuda, ‘and the Caribbean. The maximum number of letters provided for your given name (first and middle) on the card is 24 characters. If both your given names are more than 24 characters, you must shorten one of your given names you list on item #1 of Application Page 1 |» Separate mailings: You may receive your newly issued U.S. passport book and/or card and your citizenship evidence in two separate ‘mailings. f you are applying for both a book and card, you may receive three separate mailings: one with your returned evidence, one with your newly issued book, and one with your newiy issued card. All documentary evidence that is not damaged, altered, or forged will be returned to you. Photocopies will not be returned. Passport numbers: Each newly issued passport book or card will have a different passport number than your previous one. |. Shipping and Delivery Changes: If your mailing address changes prior to receipt of your new passport, please contact NPIC. NOT! We will not mail a U.S. passport to a private address outside the United States or Canada. ‘= Passport Corrections, Non-Receipt/Undeliverable Passports, and Lost/Stolen Passport: For more information visit travel. state.gov, lor contact NPIC. DS-11 04-2022 Instruction Page 3 of 4USS. Department of State APPLICATION FOR A U.S. PASSPORT False statements made knowingly and wilfully in passport applications, including affidavits or other documents submited to suppor this ‘pplication, are punishable by fine andlor imprisonment under U.S. law including the provisions of 18 U.S.C. 1001, 18 U.S.C. 1542, andlor 18 U.S.C. 1621. Alteration or mutilation of a passport issued pursuant to this application is punishable by fine andior imprisonment under the provisions of 18 U.S.C. 1543. The use of a passport in violation of the restrictions contained herein or of passport regulations is punishable by fine andlor 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 andlor the denial of Jou sppcaton. Ifany 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. Ihave not been convicted of a federal or state drug offense or convicted of a statutory “sex tourism” crime, and | 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 felon} ‘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 USC. 27114a(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 PURPOSE: We are requesting this information in order to determine your eligibil number is used to verify your identity tobe issued a U.S. passport. Your Social Security 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 responsibilty 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 State-05, Overseas Citizen 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 andlor 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({)) and may ‘subject you to penalty enforced by the Internal Revenue Service, as described in the Federal Tax Law on Instruction Page 1 (Section C) to this form. Public reporting burden for this collection of information is estimated to average 85 minutes per response, including the time required tor ‘searching existing data sources, gathering the necessary data, providing the information andor documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB 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, US. Department of State, Bureau of Consular Affairs, Passport Services, Office of Program Management and Operational Support, 44132 Mercure Cir, PO Box 1199, Sterling, Virginia 20166-1199, For more information about your application status, online tools, current fees, and processing times, please visit travel.state.gov. DS-11 04-2022 Instruction Page 4 of 4US. Department of State 8 cont No, smn APPLICATION FOR A U.S. PASSPORT —_De2taton ue: os02025 Use black ink ony. Ifyou mako an error, complete a new form. Do not correct. elect document(s) for which you are submitting fees: a U.S, Passport Book Ous. Passport Card. eased Both |S. passport a ol val fr Pamsinal avo So "Ei RogutarBock Ganda) Euarge Book (von Sardar) “The large book's for requetntemational ravers who need more visa pages. — STOP! CONTINUE TO PAGE 2—_______» PLP crane Ul Re steal Le ONS en ‘Hentifying Documents Appicantor Mother FatherParentLogal Guardian on Second Signature Line (identifying minor) Sonne Teen ree Cm oe | [ | sae [JT II ] ow | | com donttying Documents - Appcant or MotherFathedParenilLagal Guardian on Third Signature Line (tidentying minor) Kaan a cok photogs [lovmerstianss [_]Seirtmesiocas [eae [_Latiry Jem over thn Be elaine Clrceranca ton [Joven comausn et, [ | sear, IL Jexa(_T] Trent vm | ecm (ces a ot ope lee Dance mc (#0 ) fierce ey) Boe fees eu car ys ba Soe eto ne TT Bipratre ot person sctorzedto soca appicaions Dae r" Applicant's Legal Signature - age 16 and older th Seiad be spre jaro aoe ix naa Dann Wana ‘WotherFatherParentiLegal Guardian's Signature (igentyng mina) iets sctiyionurter—-* —therFatherParentegal Guardian's Signature (¥ienfyng mina) a A DS 11 C 03 2022 1 Fortesing Ofc» On) —> cue EF ___ Postage _xecuton over DS-11 04-2022, Page tof‘Name of Applicant (Last, First, & Middle) Date of Birth (mniaaiyyyy) 40, Parental information MoiherFather/Parent= First & Middle Name (al Parent's Bh) Last Name (at Paro’ Bir) Date of ith (mmr) Place of Birth (City & State itn the U.S. or City & County as tis presenty known) Gerder US. Citizen? MothedFatheriParent- First & Middle Name (at Parent's Bit) Last Name (at Paro’ it x Date of Birth (mma) Place of Birth (Cy & State itn the U.S. or Cty & County as tis presenty known) Gender U.S. Citizen? 11.Have you ever beon married? Yes No_Ifyes, complete the remaining its in #11. x Full Name of Curent Spouse or Most Recent Spouse (Ls! Ft & Ma) Date of Birth (mmdhnny) Place of ith US Citizen? Date of Mariage Have you ever been widowed or divorced? WidowiDivoree Date Yor Ne frit) we (nett) 12, Additional Contact Phone Number 13. Occupation (fage 16 orci) 14. Employer or Schoo i applicatie) 48. Travel Plans ino tava plan, please ue none’) 46.Height 16.HairColor 17, Eye Color Depart Dale immuayyyy)Ratum Oste mmvaaiyyyy) Counties tobe Visted 18, Permanent Address (Compile fP.O. Bo is Istod under Maling Adeross or esidonce is iret fom Maing Adres. Do not isa P.O. Box) ‘StresURFD # oF URB ‘AoartmentUnit cry Stale Zip Code 20. Your Emergency Contact (Prove the formation of a porson not traveling with you to bo contacted inthe event ofan emergency.) Name ‘Address: SleaURFD # or P.O. Sox AparmentUrit ity State Zip Code Phone Number Relationship 21. Have you ver applied for or been Issued a US. Passport Book or Passport Card? Yes No_Ifyes, complete the remaining itoms in #21, "Name as printod on your most recent passport book Most recent passport book number Most recent passport book issue dale nmi Salus of your most recent passport book: Submitting with application Stolen __Lost__Inmy possession if expired) [Name as printed on your most recent passport card Most recent passport card number Most recent passport card issue dale nmin Stats of your most recent passport card’ 'Submiting wit application Stolen Lost Inimiy possession (¥ expired) PLEASE DO NOT WRITE BELOW THIS LINE - FOR ISSUING OFFICE ONLY Leith codicato SR GR cy Flod [nat ict cart USCIS USDC DatePice Acquced reports Fieairace Lroespor oR SIR Seosz1 WoO! Dotrer Di amaenes Dricercte Bric orto Cos.71 Coss0s3 Doses Dos sso os-ssas Ceaw Snare DS-11 04-2022 Page 2 of 2