Fillable SECOND VALID PASSPORT STATEMENT (Ambassador Passport and Visa Services)

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SECOND VALID PASSPORT STATEMENT (Ambassador Passport and Visa Services)

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SECOND VALID PASSPORT STATEMENT
To: U.S. Department of State
Los Angeles Passport Agency
I, the undersigned, am the bearer of valid passport number_______________________issued
on (date)____________________. However, in view of the restrictive entry policies of one of
the countries that I will be visiting, or prolonged processing delays required to obtain visas for
my current travel, it is impossible for me to complete my trip utilizing my current passport.
I intend to travel to (please list countries):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Consequently, I am requesting the issuance of a second passport to facililtate my travel to the
countries mentioned above. I understand that one passport will be limited for two years and
that it may be extended at the end of that period if my need to travel to the aforementioned
countries continues.
Should either passport be lost or stolen, I will report the circumstances immediately to the
Passport Office or the nearest American Embassy or Consulate.
NAME:_______________________________SIGNATURE:___________________________
. (Please print name legibly)
DATE:_______________________________
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SECOND VALID PASSPORT STATEMENT (Ambassador Passport and Visa Services)

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Completed 16 June 2021

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