Fillable Form DS-86 STATEMENT OF NON-RECEIPT OF A U.S. PASSPORT

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Form DS-86 STATEMENT OF NON-RECEIPT OF A U.S. PASSPORT

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The Form DS-86 STATEMENT OF NON-RECEIPT OF A U.S. PASSPORT form is 1 page long and contains:

  • 1 signature
  • 5 check-boxes
  • 21 other fields

Country of origin: US
File type: PDF

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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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I, the undersigned, certify that I have not received the U.S. passport book and/or U.S. passport card for which I applied. I declare under penalty of perjury that the
statements made on this form are true and correct. I request that a new U.S. passport book and/or U.S. passport card be issued to me, and certify that if I receive the U.S.
passport book and/or U.S. passport card I reported as not received, I will immediately contact the National Passport Information Center at 1-877-487-2778 (TDD:
1-888-874-7793) and return the recovered passport to the U.S. Department of State.
Special Postage, if usedDate Mailed (mm-dd-yyyy)
Issuing Agency
Date Issued (mm-dd-yyyy)Previous U.S. Passport Card Number
Previous U.S. Passport Book Number
Issuing Agency Date Mailed (mm-dd-yyyy) Special Postage, if used
Mailing Address (as listed on original application)
Secondary Telephone Number
Primary Telephone Number
Date of Birth (mm-dd-yyyy)
Middle Name
First Name
Last Name
Social Security Number
Select the product(s) which you are reporting as not received.
U.S. Passport Book and Card
Protect yourself against identity theft! Report the non-receipt of your U.S. passport book or U.S. passport card! The information that you
provide on this form will be entered into the Consular Lost or Stolen Passport System. Upon submission of this form, you may not use
the passport(s) reported as not received for travel as the passport(s) will be invalidated. Anyone using the U.S. passport book or
U.S. passport card reported on this form, including yourself, may be detained. Should you receive the passport(s) you reported as not
received at a later time, report it as found and submit it for cancellation. See page two of this form for additional information.
Book Only Card Only
DS-86 05-2017 Page 1 of 2
ISSUING OFFICE USE ONLY
Mother/Father/Parent/Legal Guardian's Signature (if applicant is under age 16)Applicant's Signature (age 16 and older)
U.S. Department of State
OMB Approval No. 1405-0146
Expiration Date: 10-31-2020
Estimated Burden: 15 Minutes
STATEMENT OF NON-RECEIPT OF A U.S. PASSPORT
Was the passport mailed to the correct mailing address?
Yes No
Was delivery confirmed?
No
Yes
UPS
Fed Ex
Vendor:
DHLUSPS
Tracking Number:
Apartment /Unit
Street Address
City
ZIP Code
Date Issued (mm-dd-yyyy)
State
Travel Date (mm-dd-yyyy)
Date (mm-dd-yyyy)
YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW
Please explain what steps have been taken to locate the passport product(s) (Attach a separate sheet of paper if more space is needed).
Attention: Read WARNING on Page 2
Was the documentary evidence that you submitted with your original passport application returned to you?
Yes No
If no, please describe which document(s) was not received (Example: birth certificate, naturalization certificate, adoption decree, etc. Attach a
separate sheet of paper if more space is needed).
Type or print legibly in black ink in the white areas only.
IMPORTANT NOTICE
Except when authorized, a U.S. citizen may not bear more than one valid U.S. passport book and one valid U.S. passport card at a time. You have 90
days from the date that your passport document(s) was issued to report that you have not yet received it in the mail. If you do not report the
non-receipt of your U.S. passport document(s) within 90 days of the issue date, you will be required to reapply and submit the full passport fee(s). To
check the status of your U.S. passport application, please visit travel.state.gov or contact our National Passport Information Center (NPIC)
1-877-487-2778 (TDD: 1-888-874-7793).
This application must be accompanied by a clear photocopy of the front and back of a government-issued identification
document containing your photograph.
dd mmm yyyy
click to sign
signature
click to edit
HOW TO USE THIS FORM
PAPERWORK REDUCTION ACT STATEMENT
PRIVACY ACT STATEMENT
WARNING
False statements made knowingly and willfully in passport applications, or in affidavits or in other supporting documents
submitted therewith, are punishable by fine and/or imprisonment under 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 U.S. 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 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 are subject to verification.
DS-86 05-2017 Page 2 of 2
To determine how and when to use and submit this form, please call the National Passport Information Center (NPIC) at
1-877-487-2778 (TDD: 1-888-874-7793), or send an e-mail at NPIC@state.gov
. Customer Service Representatives are
available Monday-Friday 8:00a.m.-10:00p.m. and Saturday 10:00a.m.-3:00p.m. Eastern Time (excluding federal
holidays). Automated information is available 24 hours a day, 7 days a week.
AUTHORITIES: We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 22 U.S.C
2714a(f); Executive Order 11295 (August 5, 1966); and 22 C.F.R. Parts 50 and 51.
PURPOSE: The information collected on this form will be used to determine whether to issue you a replacement U.S.
passport. The collection of the Social Security number will be used for identity/entitlement to a U.S. passport for
verification only and no other purpose unless authorized by law.
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.
More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas
Citizens Services Records and Other Overseas Records and State-26, Passport Records.
DISCLOSURE: Providing information on this form is voluntary, but failure to provide your Social Security number on
your passport application may result in the denial of your application (consistent with 22 U.S.C. 2714a(f)).
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time
required for searching existing data sources, gathering the necessary data, providing the information and/or
documentation required, and reviewing the final collection. You do not have to supply this information unless the
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 U.S. Department of State, Bureau of Consular Affairs,
Passport Services, Office of Legal Affairs, Attn: Passport Forms Officer, 44132 Mercure Cir., P.O. Box 1227, Sterling,
VA 20166-1227.
For more general information, please visit our website at travel.state.gov.
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Form DS-86 STATEMENT OF NON-RECEIPT OF A U.S. PASSPORT

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Completed 18 February 2020

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