Fillable STATEMENT REGARDING A LOST OR STOLEN U.S. PASSPORT (Clerk of Vermilion Court Parish)

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STATEMENT REGARDING A LOST OR STOLEN U.S. PASSPORT (Clerk of Vermilion Court Parish)

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1. To apply for a new U.S. passport book and/or card: please submit this form with a new DS-11, Application for a U.S. Passport, to any
designated acceptance facility, U.S. passport agency, U.S. embassy, or U.S. consulate abroad.
2. If you are NOT applying for a new U.S. passport book and/or card
, submit this form AND a photocopy of a government-issued photo
identification (such as a driver's license or state-issued identification) to the following address:
3. To report a lost or stolen U. S. passpo
rt by phone, call 1-877-487-2778 and follow the representative's instructions.
4. To report a lost or stolen U. S. passport online
, please visit our website at www.travel.state.gov.
AUTHORITIES: We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E; Executive Order 11295
(August 5, 1966); and 22 C.F.R. parts 50 and 51.
PURPOSE: We are requesting the information to ensure that no one has more than one valid U.S. passport book and one valid U.S. passport card
at any one time, except as authorized by the U.S. Department of State, and to combat passport fraud and misuse.
The collection of the Social Security number will be used to verify the identity of the person reporting the lost or stolen passport 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 information can be found in System of Records Notices State-05, Overseas Citizen Services Records
and State-26, Passport Records.
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.
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.
WARNING
PRIVACY ACT STATEMENT
PAPERWORK REDUCTION ACT STATEMENT
OR
U.S. Department of State
STATEMENT REGARDING A LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD
DS-64 06-2015
Page 1 of 2
Protect yourself against identity theft! Report a lost or stolen U.S. passport !
For more information, please visit our website: www. travel.state.gov
To report a lost or stolen passport, please choose ONE of the following options:
HOW TO REPORT A LOST OR STOLEN PASSPORT BOOK AND/OR CARD
Public reporting burden for this collection of information is estimated to average ten 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: U.S. Department of State, Bureau of Consular Affairs, Passport
Services, Office of Legal Affairs and Law Enforcement Liaison, 2201 C Street NW, Washington, D.C. 20520.
OR
* 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.
OR
ATTN: CLASP
U.S. Department of State
CA/PPT/S/L/LE
44132 Mercure Cir
P.O. Box 1227
Sterling, Virginia 20166-1227
Middle Name
First NameLast Name
Date of Birth (mm-dd-yyyy)
E-mail Address
Alternative Telephone Number
Social Security Number
Has your name changed since the passport was issued? If yes, state the name in which the lost or stolen passport was issued.
Sex
List your lost or stolen U.S. Passport Book: List your lost or stolen U.S. Passport Card:
Issue
Date (mm/dd/yyyy)Number:
Issue
Date: (mm/dd/yyyy): Number:
2. LOST OR STOLEN U.S. PASSPORT BOOK/CARD INFORMATION:
Place of Birth (City & State if in U.S. or City & Country)
Female
Male
Telephone Number
()()
Current Address (Street, City, State, and ZIP Code)
Answer all questions completely. If you do not know the
answer in detail, be as exact as possible.
Explain how your U.S. passport book/card was lost or stolen.
Explain where the loss or theft occurred. Provide 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 U.S. passport book/card lost or stolen? (mm-dd-yyyy). If unknown, when was the last time you remember it in your possession?
I, the undersigned, declare under penalty of perjury all of the following: 1) That I have read and understood the warning on page one of this form;
2) The information furnished 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 and/or passport card to Passport Services at the address on page one of this form or to the nearest U.S. passport agency, U.S. embassy,
or U.S. consulate abroad.
Both parents or guardians of a child younger than 16 years old must sign this form when submitting on the child's behalf unless one parent or guardian has sole custody. If
there is sole custody, include a copy of a supporting document, such as a court order, with this form.
STATEMENT REGARDING A LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD
U.S. Department of State
OMB CONTROL NO. 1405-0014
OMB EXPIRATION DATE: 06/30/2018
ESTIMATED BURDEN: 10 Minutes
Page 2 of 2
1. IDENTIFYING INFORMATION: Type or print legibly in black ink in white areas only.
Please select the document (or documents) which you are reporting and its status.
U.S. Passport Card
Lost
Lost
Stolen Stolen
U.S. Passport Book
A U.S. citizen 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 why
the previous 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 lost or stolen passports. If more than one U.S. passport previously issued to you
was lost or stolen, your replacement passport may be limited in validity. Once reported, the lost or stolen passport is electronically cancelled and
MUST NOT 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 Unit. See
page one of this form for more information.
DS-64 06-2015
Have you had any other U.S. passport book/card lost or stolen?
Yes
No
NoYes
If yes, how many times? Approximate time frame? Did you file a police report?
Please Print Legibly Using Black Ink Only
Are you submitting this form in connection with an application for a new U.S. passport book and/or card?
Yes
No
3. YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW
Legal Signature - age 16 or older or Parent/Guardian if under age 16
Date (mm/dd/yyyy)
Legal Signature - Parent/Guardian if under age 16
Date (mm/dd/yyyy)
Did you file a police report?
Yes
No
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STATEMENT REGARDING A LOST OR STOLEN U.S. PASSPORT (Clerk of Vermilion Court Parish)

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Completed 25 July 2021

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