Fill - Free fillable APPLICATION FOR ADDITIONAL VISA PAGES OR MISCELLANEOUS PASSPORT (ILW.COM) PDF form

DS–4085 Instruction Page 1 of 3

02-2010

NOTICE TO APPLICANTS RESIDING ABROAD

United States citizens residing abroad CANNOT submit the form to the domestic addresses listed above. Such

applicants should contact the nearest U.S. embassy or consulate for procedures to be followed when applying

overseas.

PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS.

Date of Application:

FOR INFORMATION, QUESTIONS, AND INQUIRIES:

Please visit our website at travel.state.gov. In addition, you may contact the National Passport

Information Center (NPIC) toll–free at 1–877–487–2778 (TDD: 1–888–874–7793) or by email at

NPIC@state.gov. Customer Service Representatives are available M–F 6AM–12 Midnight Eastern

Time (excluding federal holidays). Automated information is available 24/7.

HOW DO I APPLY FOR ADDITIONAL VISA PAGES?

1. Co m p l e t e , s i g n a n d d a t e t h i s f o r m .

2. se n d th i s f o r m w i t h y o u r v a l i d u.s. p a s s p o r t b o o k

IS THERE A FEE ASSOCIATED WITH THIS FORM AND

HOW WILL MY NEW PASSPORT BOOK BE MAILED BACK TO ME?

WARNING: False statements made knowingly and willfully in passport applications, including afdavits or other documents submitted

to support this application, are punishable by ne and/or imprisonment under the provisions of 18 USC 1001, 18 USC 1542, and/or 18

USC 1621. Alteration or mutilation of a passport issued pursuant to this application is punishable by ne and/or imprisonment under

the provisions of 18 USC 1543. The use of a passport in violation of the restrictions contained therein or of the passport regulations is

punishable by ne and/or imprisonment under 18 USC 1544. All statements and documents are subject to verication.

• THE CURRENT PASSPORT FEE: Please visit our website at travel.state.gov for current fees. MAKE CHECKS OR MONEY ORDERS PAYABLE

TO “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 fees are

not refundable. Your U.S. passport book will be returned to you by priority mail.

• OVERNIGHT DELIVERY SERVICE: If you desire overnight delivery for the return of your passport, please include the appropriate fee with your

application.

• FASTER PROCESSING: For an additional fee, you may request expedited service. Please include this fee with your application and mail to the

appropriate address. Please write “Expedite” on the outer envelope when mailing. TO ENSURE MINIMAL PROCESSING TIME for

expedited applications, Passport Services recommends using overnight delivery when submitting the application AND including

the appropriate postage fee for return overnight delivery for the completed passport book. Expedited service is available only in the

United States. Please consult our website for updated fee information and processing times.

NOTE: The Passport Center will not mail a passport book to a private address outside the United States.

NOTE: If you choose to provide your e-mail address in Item #8 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 you need to provide additional information to us.

MAIL THIS FORM TO:

National Passport Processing Center

Post Ofce Box 90106

Philadelphia, PA 19190-0106

MAIL THIS FORM TO:

National Passport Processing Center

Post Ofce Box 90906

Philadelphia, PA 19190-0906

ROUTINE SERVICE EXPEDITED SERVICE (Additional Fee)

APPLICATION FOR ADDITIONAL VISA PAGES

OR MISCELLANEOUS PASSPORT SERVICES

DS–4085 Instruction Page 2 of 3

02-2010

Section 6039E of the Internal Revenue Code (26 U.S.C. 6039E) 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 name of the foreign country in which you are residing. The Department of State must

provide your SSN and foreign residence information to the Department of Treasury. If you fail to provide the information, you are subject

to a $500 penalty enforced by the IRS. All questions on this matter should be directed to the nearest IRS ofce.

FEDERAL TAX LAW

NOTICE TO CUSTOMERS MAKING PAYMENT BY CHECK

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 be-

cause of insufcient funds, we may try to make the transfer up to two times and we will charge you a one–time fee of $25, which we will

also collect by EFT.

REMITTANCE OF FEES

31 U.S.C. 7701 requires persons “doing business” with a federal agency to provide their Social Security Numbers to that agency. Because

the Department of State collects fees for the provision of passport services to you, you are considered a person “doing business” with the

Department. Passport service fees are established by law and regulation (see 22 U.S.C. 214, 22 CFR 22.1, and 22 CFR 51.50–56) and are

collected at the 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 your credit card, the 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 ar-

rangements have been made, the Department will refer the debt to the Department of Treasury for collection. Debt collection procedures

used by 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.

IMPORTANT NOTICE TO APPLICANTS WHO HAVE LOST OR HAD A PREVIOUS PASSPORT BOOK

AND/OR PASSPORT CARD STOLEN

A United States citizen may not normally bear 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 U.S. passport card cannot be presented

with a new application, it is necessary to submit a Form DS-64, Statement Regarding a Lost or Stolen Passport. Your statement must detail

why the previous U.S. passport book or U.S. passport card cannot be presented.

The information you provide regarding your lost or stolen U.S. passport book or passport 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 passport card. Anyone using

the passport book or passport card reported as lost or stolen may be detained upon entry into the United States. Should you locate the

U.S. passport book or passport card reported lost or stolen at a later time, report it as found and submit it for cancellation. It has been

invalidated. You may not use that passport book or passport card for travel.

PROTECT YOURSELF AGAINST IDENTITY THEFT

REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD!

For more information or to report your lost or stolen passport book or passport card by phone, call NPIC or visit our website at

travel.state.gov.

OTHER USES OF SOCIAL SECURITY NUMBERS

In addition to reporting your Social Security Number to Treasury and using it in connection with debt collection, the Department checks Social

Security Numbers against lists of persons ineligible or potentially ineligible to receive a U.S. passport.

You are not required to provide the information requested on this form unless the form displays a currently valid OMB number. We try to

create forms and instructions that can be easily understood. Often this is difcult to do because our citizenship laws are very complex. The

estimated burden time for this information collection is 20 minutes, which includes the time required to search existing data sources, gather

the necessary data, complete 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 can write to us at: U.S. Department of State (A/ISS/DIR) Washington, DC 20520.

PAPERWORK REDUCTION STATEMENT

DS–4085 Instruction Page 3 of 3

02-2010

(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 afrmation) by the applicant should be attached and made a part of

this application.) I have not, since acquiring United States citizenship/nationality, been naturalized as a citizen of a foreign state; taken an

oath or made an afrmation or other formal 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 ofce, post, or employment under the government of a foreign state or political subdivision

thereof; made a formal renunciation of nationality either in the United States, or before a diplomatic or consular ofcer of the United States

in a foreign state; or been convicted by a court or court martial of competent jurisdiction of committing any act of treason against, or at-

tempting by force to overthrow, or bearing arms against, the United States, or conspiring to overthrow, put down, or to destroy by force,

the Government of the United States.

ACTS OR CONDITIONS

AUTHORITIES: Collection of the information solicited on this form is authorized by Titles 8, 22, and 26 of the United States Code, whether

or not codied, including specically 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 entitlement 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 adjudicating passport applications and requests for related services, and for law enforcement and administra-

tive purposes. The information may be made available to foreign government agencies to fulll 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: 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.

PRIVACY ACT STATEMENT

ELECTRONIC PASSPORT STATEMENT

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.

The State Department has begun issuing a new type of passport book containing an embedded electronic chip and called an “Electronic

Passport”. The new passport book continues to be proof of the bearer’s United States citizenship/nationality and identity, and looks and

functions in the same way as a passport without a chip. The addition of an electronic chip in the back cover enables the new passport book

to carry a duplicate electronic copy of all information from the data page. The new passport book is usable at all ports–of–entry, including

those that do not yet have electronic chip readers.

Use of the electronic format provides the traveler the additional security protections inherent in chip technology. Moreover, when used at

ports–of–entry equipped with electronic chip readers, the new passport book provides for faster clearance through some of the port–of–entry

processes.

The new passport book does not require special handling or treatment, but like previous versions should be protected from extreme bend-

ing and from immersion in water. The electronic chip must be read using specially formatted readers, which protects the data on the chip

from unauthorized reading.

The cover of the new passport book is printed with a special symbol representing the embedded chip. The symbol will appear in

port–of–entry areas where the electronic passport book can be read.

APPLICATION FOR ADDITIONAL VISA PAGES

OR MISCELLANEOUS PASSPORT SERVICES

This section for

issuing ofce only

Page 1 of 1

DS-4085 02-2010

YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW

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, since acquiring U.S. citizenship or nationality, performed any of the acts

listed under “Acts or Conditions” on the reverse side 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.

WARNING: False statements made knowingly and willfully in passport applications, including

afdavits or other documents submitted to support this application, are punishable by ne

and/or imprisonment under the provisions of 18 USC 1001, 18 USC 1542, and/or 18 USC 1621.

Alteration or mutilation of a passport issued pursuant to this application is punishable by ne

and/or imprisonment under the provisions of 18 USC 1543. The use of a passport in violation

of the restrictions contained therein or of the passport regulations is punishable by ne and/or

imprisonment under 18 USC 1544. All statements and documents are subject to verication.

x ____________________________________________________

Applicant’s Signature - age 16 and older

x ____________________________________________________

Parent’s/Legal Guardian’s Signature

(if identifying minor)

_________________________________________________

Date

12. Occupation 13. Employer

11. Additional Contact Phone Number

Home

Work

Cell

_________

City

14. 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 P.O. Box

City

Name

State

Zip Code

Relationship

Phone Number

15. Travel Plans

Date of Trip

(mm/dd/yyyy)

Length of Trip Countries to be visited

Issue date

(mm/dd/yyyy)

State Zip Code

9. Current Passport Number

10. Permanent Address:

Street/RFD # (No P.O. Box)

City

OMB APPROVAL NO. 1405-0159

EXPIRATION DATE: 12-31-2010

ESTIMATED BURDEN: 20 MIN

1. Name

Last

2. Date of Birth

(mm/dd/yyyy)

Home

Work

Cell

7. Contact Phone Number

- -

8. Email Address

(Optional)

First & Middle

EF________ Postage________ Other________

5. Social Security Number

3. Sex

4. Place of Birth

(City & State or City & Country as it is presently known)

State

6. Mailing Address:

Street/RFD # or P.O. Box

In Care Of or Country, if applicable

City

Apartment or unit #

Zip Code

(Zip + 4 if known)

Apartment or unit #

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