Middle Name
First NameLast Name
Date of Birth (mm-dd-yyyy)
E-mail Address
Work 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:
2. LOST OR STOLEN U.S. PASSPORT BOOK/CARD INFORMATION:
Place of Birth (City & State if in U.S. or City & Country)
List your lost or stolen U.S. Passport Card:
Female
Male
Home Telephone Number
()()
Current Address (Street, City, State, and ZIP Code)
Issue
Date (mm/dd/yyyy)
Number:
Issue
Date: (mm/dd/yyyy):
Number:
Answer all questions completely. If you do not know the
answer in detail, be as exact as possible.
2a. Explain how the document(s) were lost or stolen.
2b. Explain where the loss or theft occurred. Provide Address if known (City/State)
2c. On what date was your document(s) 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 it 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.
For a child under 16, this form must be signed by both parents or the child's legal guardian(s). In case of sole custody, include a copy of the
supporting document (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: 08/31/2015
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 their status.
U.S. Passport Card
Lost
Lost
Stolen Stolen
U.S. Passport Book
IMPORTANT NOTICE
A U.S. citizen may not normally bear more than one valid or potentially valid U.S. passport book and one valid U.S. passport card at a time. It
therefore is necessary to submit a statement with an application for a new U.S. passport when a previously issued valid or potentially valid U.S.
passport book/card cannot be presented. Your statement must detail why the previous U.S. passport book/card cannot be presented. The
information you provide on the DS-64, "Statement Regarding a Lost or Stolen U.S. Passport Book and/or Card", will be placed into our Consular
Lost and Stolen Passport System. This system is designed to prevent the misuse of your lost or stolen U.S. passport book/card. Anyone using a
U.S. passport book/card reported on the DS-64, including yourself, may be detained upon entry into the United States. Should you locate the
reported lost or stolen U.S. passport at a later time, submit it for cancellation to the Consular Lost and Stolen Unit. It has been invalidated. You
may not use that U.S. passport for travel. See page one of this form for additional information.
DS-64 08-2013
2d. Have you had other U.S. passport book/card lost or stolen? How many times? What were the dates? Did you file a police report?
Please Print Legibly Using Black Ink Only
2e. Are you submitting this form in connection with an application for a new U.S. passport book and/or card?
Yes No
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 - age 16 or older or Parent/Guardian if under age 16
Date (mm/dd/yyyy)
