Fillable Form 2.: STATEMENT REGARDING A VALID LOST OR (U.S. Department of State)

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Form 2.: STATEMENT REGARDING A VALID LOST OR (U.S. Department of State)

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The US Department of State (DOS) or the State Department, is the government official division that advises the President and performs international relations. Equivalent to the outside service of different nations, it was built up in 1789 as the country's first official department.

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U.S. Department of State
OMB Control No. 1405-0014
Expiration Date: 
Estimated Burden: 5 Minutes
Page 1 of 2
DS-64 
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To report a valid lost or stolen passportERRNDQGRUFDUG please choose ONE of the following options:
1. ONLINE:Visit our website at travel.state.gov.
OR
OR
3. BY PHONE:Call 1-877-487-2778 (TDD: 1-888-874-7793) and follow the representative's instructions.This option is not
available for customers abroad.
OR
4. BY MAIL:Submit this form AND a front and back photocopy of a government-issued photo identification (such as a driver's
license or state-issued identification) to the following address ONLY IF you are NOT applying for a new U.S.
passport bookand/or card:
ATTN: CLASP
U.S. Department of State
CA/PPT/S/50&/$63
44132 Mercure Cir
P.O. Box 1227
Sterling, VA 20166-1227
* Only use this address to submit this form or other correspondence about lost/stolen passports. For general inquiries, call the
National Passport Information Center at 1-877-487-2778.
Protect yourself against identity theft! Report a lost or stolen U.S. passport!
For more information, please visit our website: travel.state.gov
:$51,1*
False statements made knowingly and willfully on this form, in U.S. passport applications, or in affidavits or other supporting
documents submitted therewith are punishable by fine and/or imprisonment under U.S. law, including the 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 the
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.
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AUTHORITIES:We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 8 U.S.C. 1737; Executive
Order 11295 (August 5, 1966); and 22 C.F.R. Parts 50 and 51.
PURPOSE:7he information UHTXHVWHGRQWKLVIRUPLVXVHGto ensure that no one has more than one valid U.S. passport book
DQGRQHYDOLG86passport card at any one time, except as authorized by the U.S. Department of State, and to combat passport
IUDXGDQGPLVXVH7he collection of the Social Security number will be used to verify the identity of the person reporting the lost
RUVWROHQSDVVSRUWDQGto identify the passport being reported lost or stolen. There is no other purpose unless authorized by law.
DISCLOSURE: Providing your Social Security number and other information on this form is voluntary, but failure to provide the
information on this form may, given the form's purpose of verification of your identity, result in processing delays.
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Public reporting burden for this collection of information is estimated to average five minutes per response, including 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 OMB control
number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them
to: 3DVVSRUW)RUPV2IILFHUU.S. Department of State, Bureau of Consular Affairs, Passport Services, Office of Program Management
DQG2SHUDWLRQDOSupport, 44132 Mercure Cir., P.O. Box 1199, Sterling, VA 20166-1199.
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STATEMENT REGARDING A VALID LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD
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2.
WHILE APPLYING FOR A
NEW U.S. PASSPORT:Submit this form with
a new DS-11, Application for DU.S.
Passport along ZLWK
required documentation to any designated acceptance facility,
U.S.
passport agency, U.S. embassy, or U.S. consulate abroad.
U.S. Department of State
STATEMENT REGARDING A VALID LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD
OMB Control No. 1405-0014
Expiration Date: 
Estimated Burden: 5 Minutes
Page 2 of 2
DS-64 
IMPORTANT NOTICE
A U.S. national may not normally bear more than one valid or potentially valid U.S. passport book and/or card at a time. Therefore, a statement is required when
applying for a new U.S. passport if the previously valid or potentially valid passport is not submitted. Your statement must detail Zhy the previous valid U.S. passport
cannot be presented.The information you provide on this form will be placed into the Consular Lost and Stolen Passport System, which is designed to prevent the
misuse of all reported valid lost or stolen U.S. passports. If more than one valid U.S. passport previously issued to you was lost or stolen, your replacement passport
may be limited in validity. ONCE REPORTED, THE VALID LOST OR STOLEN PASSPORT IS ELECTRONICALLY CANCELLED AND CANNOT BE USED FOR
TRAVEL. Anyone (including the bearer) traveling on a reported lost or stolen passport may be detained upon entering the United States. Should you locate the passport
after reporting it lost or stolen, submit it for cancellation to the Consular Lost and Stolen Passport Unit (CLASP). See page one of this form for contact information.
Please select the document (or documents) that you are reporting and its status.
Valid U.S. Passport
Book
Lost Stolen
Valid U.S. Passport
Card
Lost Stolen
Are you submitting this form in connection with an application for a new U.S. passport book and/or card?
Yes No
Last Name
First Name
Middle Name
Has your name changed since the passport was issued? If yes, state the name in which theYDOLG lost or stolen passport was issued.
Date of Birth (mm-dd-yyyy)
Place of Birth (City & State if in U.S. or City & Country)
Social Security Number
Current Address (Street, City, State, and ZIP Code or Country, if outside the U.S.)
Telephone Number
Alternative Telephone Number
Email Address
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Explain in detail how your valid U.S. passport book/card was lost or stolen. Include a photocopy of the valid passport book/card if available.
Explain where the loss or theft occurred. Provide the address, if known (City and State, if in the U.S., or City and Country as it is presently known)
On what date was your valid U.S. passport book/card lost or stolen (mm-dd-yyyy)? If unknown, when was the last time you remember it being in your possession?
Did you file a police report? (If yes and the report is available, please submit a copy.)
Yes No
List your valid lost or stolen U.S. Passport
Book
, if known: List your valid lost or stolen U.S. Passport
Card
, if known:
Number Issue Date
(mm-dd-yyyy)
Number Issue Date
(mm-dd-yyyy)
Have you had any other valid U.S. passport book/card lost or stolen?
Yes No
If yes, how many passports?
Approximate date(s)?
(mm-dd-yyyy)
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I, the undersigned, declare under penalty of perjury all of the following: 1) that I have read and understDQG the warning on page one of this form; 2)
the information provided herein is correct and complete; 3) I have not given my U.S. passport book and/or passport card to another person or disposed
of it in an unauthorized manner; 4) I understand that the U.S. passport(s) I report as missing will be invalidated and cannot be used; and 5) if I
subsequently find and recover it, I will immediately return the passport ERRNand/or passport card to Passport Services at the address on page one of
WKLVform or to the nearest U.S. passport agency, U.S. embassy or U.S. consulate if abroad, and I will not attempt to use it.
Applicant's Legal Signature - age 16 or older
Mother/Father/Parent/Guardian Legal Signature if identifying minor under age 16
Mother/Father/Parent/Guardian Legal Signature if identifying minor under age 16
Both parents or guardians of a child younger than 16 years old must sign and provide a front and back photocopy of ID when submitting this form
on the child's behalf unless one
parent or guardian has sole authority to obtain a passport pursuant to 22 C.F.R. 51.28. If there is sole authority, include a copy of a supporting document with this form, such as a court order
proving sole legal custody or form DS-5525, Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor Under Age 16.
Please Print Legibly RU7\SHUsing Black Ink Only.
Did you file a police report? (If yes and the report is available, please submit a copy.) Yes No
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CLEAR
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Form 2.: STATEMENT REGARDING A VALID LOST OR (U.S. Department of State)

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Completed 9 February 2022

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