HOW TO USE THIS FORM
PAPERWORK REDUCTION ACT STATEMENT
PRIVACY ACT STATEMENT
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.
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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,
For more general information, please visit our website at travel.state.gov.