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I have changed my name since my most recent U.S. passport book
and/or U.S. passport card was issued less than one year ago;
OR
My identifying information in my most recent U.S. passport book and/or U.S.
passport card was printed incorrectly;
OR
My most recent, full-fee U.S. passport book was limited in validity, and was issued
less than one year ago.
OR
My most recent, full-fee U.S. passport book was limited in validity due to a lost
naturalization certificate or due to gender transition, and was issued less than
two years ago.
APPLICATION FOR A U.S. PASSPORT
NAME CHANGE, DATA CORRECTION, AND LIMITED PASSPORT BOOK REPLACEMENT
PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS
CAN I USE THIS FORM?
Complete this checklist to determine your eligibility to use this form
Yes
Yes
You must apply on application form DS-11 or DS-82 depending on your circumstances. Please refer to those forms, visit
travel.state.gov
, or contact the National Passport Information Center for further information.
Yes
No
No
No
Date of Application:____________________________
INFORMATION, QUESTIONS, AND INQUIRIES
U.S. PASSPORTS, EITHER IN BOOK OR CARD FORMAT, ARE ISSUED ONLY TO U.S. CITIZENS OR NON-CITIZEN NATIONALS. EACH PERSON
MUST OBTAIN HIS OR HER OWN PASSPORT BOOK OR PASSPORT CARD. THE PASSPORT CARD IS A U.S. PASSPORT ISSUED IN CARD
FORMAT. LIKE THE TRADITIONAL PASSPORT BOOK, IT REFLECTS THE BEARER'S ORIGIN, IDENTITY, AND NATIONALITY AND IS SUBJECT TO
EXISTING PASSPORT LAWS AND REGULATIONS. UNLIKE THE PASSPORT BOOK, THE PASSPORT CARD IS VALID ONLY FOR ENTRY TO THE
UNITED STATES AT LAND BORDER CROSSINGS AND SEA PORTS OF ENTRY WHEN TRAVELING FROM CANADA, MEXICO, THE CARIBBEAN,
AND BERMUDA. THE U.S. PASSPORT CARD IS NOT VALID FOR INTERNATIONAL AIR TRAVEL.
Please visit our website at travel.state.gov. In addition, you may contact the National Passport Information
Center (NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by email at NPIC@state.gov
. Customer
Service Representatives are available Monday-Friday 8:00a.m.-10:00p.m. Eastern Time (excluding federal
holidays.) Automated information is available 24 hours a day, 7 days a week.
Instruction Page 1 of 4
FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM, INCLUDING YOUR SOCIAL SECURITY NUMBER,
MAY RESULT IN SIGNIFICANT PROCESSING DELAYS AND/OR THE DENIAL OF YOUR APPLICATION.
NOTICE TO APPLICANTS RESIDING ABROAD
United States citizens residing abroad CANNOT submit this form to the domestic address listed on the Instruction Page 2. Such applicants should contact the
nearest U.S. Embassy or Consulate for procedures to be followed when applying overseas.
DS-5504 11-2013
WARNING: False statements made knowingly and willfully in passport applications, including affidavits or other documents submitted to support
this application, are punishable by fine and/or imprisonment under U.S. law, including 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 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 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.
See page 2 of the instructions for detailed information on the completion and submission of this form.
If you choose to provide your email address in Item #6 on this application, Passport Services may use that information to contact you in the event there is a
problem with your application or if additional information is required.
If you answered NO to ALL of the four statements above,
STOP - You cannot use this form!
No
Yes
WHAT DO I SEND WITH THIS APPLICATION FORM?
1. Your most recent U.S. passport book and/or passport card.
2. A recent color photograph.
Submit a color photograph of you alone, sufficiently recent to be a good likeness of you (taken within the last six months), and 2x2 inches in size. The
image size measured from the bottom of your chin to the top of your head (including hair) should not be less than 1 inch, and not more than 1 3/8 inches. The
photograph must be color, clear, with a full front view of your face, and printed on thin paper with plain light (white or off-white) background. The photograph
must be taken in normal street attire, without a hat, head covering, or dark glasses unless a signed statement is submitted by the applicant verifying the item is
worn daily for religious purposes or a signed doctor's statement is submitted verifying the item is used daily for medical purposes. Headphones, "bluetooth", or
similar devices must not
be worn in the passport photograph. Any photograph retouched so that your appearance is changed is unacceptable. A snapshot,
most vending machine prints, and magazine or full-length photographs are unacceptable. A digital photo must meet the previously stated qualifications, and will
be accepted for use at the discretion of Passport Services. (Visit our website at travel.state.gov
for details and information.)
3. Evidence to support a name change or other change in descriptive data.
If your name has changed, the name change document you submit must be a certified copy of your marriage certificate or a certified copy of a court order
showing a seal and officiate/judge signature. If you are unable to document your name change in this manner, you must apply on the DS-11 application form by
making a personal appearance at (1) a passport agency; (2) U.S. Embassy or Consulate, if abroad; (3) any federal or state court of record or any probate court
accepting passport applications; (4) a designated municipal or county official; or (5) a post office, which has been selected to accept passport applications.
If there is a change or an error in the descriptive data in your recently issued passport, you must submit the appropriate evidence showing the correct
information (e.g. certified birth certificate or certified marriage certificate as described above).
All documentary evidence that is not damaged, altered, or forged will be returned to you.
PLEASE NOTE: If you are re-applying, because your U.S. passport book was limited in validity due to a lack of citizenship evidence or identity,
please submit the necessary document as specified by Passport Services. Passports limited in validity due to multiple losses cannot be extended.
Please contact the National Passport Information Center for detailed information and instructions.
HOW DO I APPLY USING THIS FORM?
MAIL FORM TO:
FOR ROUTINE SERVICE:
National Passport Processing Center
Post Office Box 90107
Philadelphia, PA 19190-0107
FOR EXPEDITED SERVICE (Additional Fee):
National Passport Processing Center
Post Office Box 90907
Philadelphia, PA 19190-0907
IS THERE A FEE ASSOCIATED WITH THIS FORM AND HOW WILL MY NEW
U.S. PASSPORT BOOK AND/OR PASSPORT CARD BE MAILED BACK TO ME?
There is no fee associated with the use of this form unless expedited service is requested (see below). Your re-issued passport book and/or passport card and
any documentary evidence submitted to Passport Services will be returned to you by priority or first class mail, unless overnight delivery is requested. You
may receive your newly issued document and your returned citizenship evidence in separate mailings. If you are applying for both a U.S. passport book and
card you may receive three separate mailings; one with your returned citizenship evidence; one with your newly issued U.S. passport book, and one with
your newly printed U.S. passport card.
OVERNIGHT DELIVERY SERVICE
: If you desire overnight delivery service for the return of your passport, include the appropriate fee with your payment.
FASTER PROCESSING
: For an additional fee, you may request expedited service. Please include this fee in your payment, and submit the application to the
appropriate address. Please write "Expedite" on the outer envelope when mailing. ALSO, TO ENSURE MINIMAL PROCESSING TIME
for expedited
applications, Passport Services recommends using overnight delivery when submitting the application AND including the appropriate postage fee
for return overnight delivery for the completed passport. Expedited service is only available in the United States. Please visit travel.state.gov
for
updated information regarding fees and processing times.
Enclose the expedite and/or overnight delivery fee in the form of a personal check or money order. MAKE CHECKS PAYABLE TO "U.S. DEPARTMENT OF
STATE." THE FULL NAME AND DATE OF BIRTH OF THE APPLICANT MUST BE TYPED OR PRINTED ON THE FRONT OF THE CHECK. DO NOT
SEND CASH. Passport Services cannot be responsible for cash sent through the mail. By law, the fees are non-refundable. Please visit our website at
travel.state.gov
for detailed information regarding current fees.
NOTE REGARDING MAILING ADDRESSES: Passport Services will not mail a passport to a private address outside the United States. If you do not live at
the address listed in the "mailing address", then you must put the name of the person, and mark it as "In Care Of." If your mailing address changes prior to
receipt of your new U.S. passport, please contact the National Passport Information Center at 1-877-487-2778 or visit travel.state.gov
.
Instruction Page 2 of 4
1. Complete, sign, and date this form.
2. Send this form with your most recent U.S. passport book and/or passport card, any required additional evidence, and a recent color photograph.
DS-5504 11-2013
Because of the sensitivity of the enclosed documents, Passport Services recommends using trackable mailing service when submitting your application.
Instruction Page 3 of 4
If you send us a check, it will be converted into an electronic funds transfer (EFT). This means we will copy your check, and use the account
information on it to electronically debit your account for the amount of the check. The debit from your account will usually occur within 24 hours,
and will be shown on your regular account statement.
You will not receive your original check back. We will destroy your original check, but we will keep the copy of it. If the EFT cannot be processed
for technical reasons, you authorize us to process the copy in place of your original check. If the EFT cannot be completed because of insufficient
funds, we may try to make the transfer up to two times, and we will charge you a one-time fee of $25, which we will also collect by EFT.
NOTICE TO CUSTOMERS APPLYING OUTSIDE A STATE DEPARTMENT FACILITY
Passport service fees are established by law and regulation (see 22 U.S.C. 214, 22 C.F.R. 22.1, and 22 C.F.R. 51.50-56) and are collected at the
time you apply for the passport service. If the Department fails to receive full payment of the applicable fees because, for example, your check is
returned for any reason or you dispute a passport fee charge to your credit card, the U.S. Department of State will take action to collect the
delinquent fees from you under 22 C.F.R. Part 34, and the Federal Claims Collection Standards (see 31 C.F.R. Parts 900-904). In accordance with
the Debt Collection Improvement Act (Pub.L. 104-134), if the fees remain unpaid after 180 days and no repayment arrangements have been made,
the U.S. Department of State will refer the debt to the U.S. Department of Treasury for collection. Debt collection procedures used by the U.S.
Department of Treasury may include referral of the debt to private collection agencies, reporting of the debt to credit bureaus, garnishment of
private wages and administrative offset of the debt by reducing or withholding eligible federal payments (e.g., tax refunds, social security payments,
federal retirement, etc.) by the amount of your debt, including any interest penalties or other costs incurred. In addition, non-payment of passport
fees may result in the invalidation of your passport. An invalidated passport cannot be used for travel.
REMITTANCE OF FEES
IMPORTANT NOTICE TO APPLICANTS WHO HAVE LOST OR HAD A PREVIOUS U.S. PASSPORT BOOK
AND/OR PASSPORT CARD STOLEN
A United States citizen may not normally bear more than one valid or potentially valid U.S. passport book or more than one valid or potentially valid
U.S. passport card at a time. Therefore, when a valid or potentially valid U.S. passport book or U.S. passport card cannot be presented with a new
application, it is necessary to submit a Form DS-64, Statement Regarding a Lost or Stolen U.S. Passport. Your statement must detail why the
previous U.S. passport book or U.S. passport card cannot be presented.
The information you provide regarding your lost or stolen U.S. passport book or passport card will be placed into our Consular Lost or Stolen
Passport System. This system is designed to prevent the misuse of your lost or stolen U.S. passport book or passport card. Anyone using the
passport book or passport card reported as lost or stolen may be detained upon entry into the United States. Should you locate the U.S. passport
book or passport card reported lost or stolen at a later time, report it as found, and submit it for cancellation. It has been invalidated
. You may not
use that passport book or passport card for travel.
PROTECT YOURSELF AGAINST IDENTITY THEFT!
REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD!
DS-5504 11-2013
NOTICE TO APPLICANTS FOR OFFICIAL, DIPLOMATIC, OR NO-FEE PASSPORTS
You may use this application if you meet the provisions listed, however, you must CONSULT YOUR SPONSORING AGENCY FOR
INSTRUCTIONS ON PROPER ROUTING PROCEDURES BEFORE FORWARDING THIS APPLICATION. Your completed passport will be
released to your sponsoring agency for forwarding to you.
For more information or to report your lost or stolen U.S. passport book or passport card by phone, call NPIC or visit our website at travel.state.gov.
SPECIAL NOTICE TO U.S. PASSPORT CARD APPLICANTS ONLY
The maximum number of letters provided for your given name (first and middle) on the U.S. Passport Card is 24 characters. The 24 characters may be
shortened due to printing restrictions. If both your given names are more than 24 characters, you must shorten the given name you list on item 1 of this form.
Instruction Page 4 of 4
ACTS OR CONDITIONS
If any of the below-mentioned acts or conditions have been performed by or apply to the applicant, the portion which applies should be lined out,
and a supplementary explanatory statement under oath (or affirmation) by the applicant should be attached and made a part of this application.
I have not, since acquiring United States citizenship/nationality, been naturalized as a citizen of a foreign state; taken an oath or made an
affirmation or other formal declaration of allegiance to a foreign state; entered or served in the armed forces of a foreign state; accepted or
performed the duties of any office, post, or employment under the government of a foreign state or political subdivision thereof; made a formal
renunciation of nationality either in the United States, or before a diplomatic or consular officer of the United States in a foreign state; or been
convicted by a court or court martial of competent jurisdiction of committing any act of treason against, or attempting by force to overthrow, or
bearing arms against, the United States, or conspiring to overthrow, put down, or to destroy by force, the government of the United States.
Furthermore, I have not been convicted of a federal or state drug offense or convicted for “sex tourism” crimes statute, and I am not the subject of
an outstanding federal, state, or local warrant of arrest for a felony; a criminal court order forbidding my departure from the United States; a
subpoena received from the United States in a matter involving federal prosecution for, or grand jury investigation of, a felony.
PRIVACY ACT STATEMENT
AUTHORITIES: We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; Executive Order 11295 (August 5, 1966);
and 22 C.F.R. parts 50 and 51.
PURPOSE: We are requesting this information in order to determine your entitlement to receive the passport service for which you are applying.
The collection of the Social Security number will be used for identity/entitlement 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 Citizen Services Records
and State-26, Passport Records.
DISCLOSURE: Providing your Social Security number and the 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 or entitlement, result in processing delays or denial of your application.
ELECTRONIC PASSPORT STATEMENT
The U.S. Department of State now issues an "Electronic Passport" book, which contains an embedded electronic chip. The electronic passport
book continues to be proof of the bearer's United States citizenship/nationality and identity, and looks and functions in the same way as a passport
without a chip. The addition of an electronic chip in the back cover enables the passport book to carry a duplicate electronic copy of all information
from the data page. The electronic passport book is usable at all ports-of-entry, including those that do not yet have electronic chip readers.
Use of the electronic format provides the traveler the additional security protections inherent in chip technology. Moreover, when used at
ports-of-entry equipped with electronic chip readers, the electronic passport book provides for faster clearance through some of the port-of-entry
processes.
The electronic passport book does not require special handling or treatment, but like previous versions should be protected from extreme heat,
bending, and from immersion in water. The electronic chip must be read using specially formatted readers, which protects the data on the chip
from unauthorized reading.
The cover of the electronic passport book is printed with a special symbol representing the embedded chip. The symbol will appear in
port-of-entry areas where the electronic passport book can be read.
DS-5504 11-2013
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 40 minutes per response, including the 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 Program Management and Operational Support, 2201 C Street NW, Washington, D.C. 20520.
I declare under penalty of perjury all of the following: 1) I am a citizen or non-citizen national of the United States and have not, since acquiring U.S. citizenship or nationality,
performed any of the acts listed under "Acts or Conditions" on page four of the instructions of this application (unless explanatory statement is attached); 2) the statements made on
the application are true and correct; 3) I have not knowingly and willfully made false statements or included false documents in support of this application; 4) the photograph
submitted with this application is a genuine, current photograph of me; and 5) I have read and understood the warning on page one of the instructions to the application form.
Applicant's Legal Signature - age 16 and older
x
x
FOR ISSUING OFFICE ONLY
Name Change
Other:
Attached:
EF
Postage Other
APPLICATION FOR A U.S. PASSPORT
OMB CONTROL NO. 1405-0160
OMB EXPIRATION DATE: 01-31-2017
ESTIMATED BURDEN: 40 MIN
STAPLE
2" x 2"
2" x 2"
STAPLE
STAPLESTAPLE
YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW
Page 1 of 2
DS-5504 11-2013
* DS 5504 C 11 2013 1 *
Please Print Legibly Using Black Ink Only
10. U.S. Passport Book and/or Passport Card Information
Your name as printed on your most recent U.S. passport book and/or passport card
Most recent U.S. passport book number
Most recent U.S. passport card number
Book Issue Date (mm/dd/yyyy)
Card Issue Date (mm/dd/yyyy)
D
End. #
O DP DOTS Code
Exp.
CONTINUE TO PAGE 2
Date
Mother/Father/Parent/Legal Guardian's Signature (if identifying minor)
BC Nat/Citz Cert Report of Birth Prev PPT MC Adoption C/O NC C/O PIERS Other
Filed/Issued/Place: Doc #:
From:
To:
Attention: Read WARNING on page 1 of instructions
Please select the document(s) for which you are applying:
U.S. Passport Book
U.S. Passport Card
28 Page Book (Standard)
The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions.
Note: The 52 page option is for those who frequently travel abroad during the passport validity period and is recommended
for applicants who have previously required the addition of visa pages.
A. B.
City Zip Code
Country, if outside the United States
State
9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed.)
Address Line 2: Clearly label Apartment, Company, Suite, Unit, Building, Floor, In Care Of or Attention if applicable. (e.g., In Care Of - Jane Doe, Apt # 100)
4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.)
First
Middle
-
-
MF
3. Sex
6. Email Address (e.g., my_email@domain.com)
@
7. Primary Contact Phone Number
5. Social Security Number
2. Date of Birth (mm/dd/yyyy)
--
-
1. Name Last
-
8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.
Replacement Correction: LName FName MName DOB Sex POB Other
NAME CHANGE, DATA CORRECTION, AND LIMITED PASSPORT BOOK REPLACEMENT
Both
52 Page Book (Non-Standard)
Attach a color photograph
taken within the last six months
Please complete the following questions regarding your current passport book and/or passport card
16. Additional Contact Phone Numbers
11. Height 12. Hair Color 13. Eye Color
14. Occupation (if age 16 or older)
15. Employer or School (if applicable)
17. Permanent Address: If P.O. Box is listed under Mailing Address or
if residence is different from Mailing Address.
Apartment/Unit
City
State
18. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency.
Name Apartment/Unit
City Relationship
19. Travel Plans
Departure Date (mm/dd/yyyy)
Countries to be visited
Zip Code
Address: Street/RFD # or P.O. Box
State
Zip Code Phone Number
Return Date (mm/dd/yyyy)
Street/RFD # or URB (No P.O. Box)
Date of Birth (mm/dd/yyyy) Name of Applicant (Last, First & Middle)
Home Cell
Work
DS-5504 11-2013 Page 2 of 2
Has your name changed by marriage or court
order since your U.S. passport book or
passport card was issued?
If yes, please complete this section with your
current information.
Note: To complete a name change your submitted U.S. passport book and/or passport card must be less than one year old.
Please submit evidence documenting your name change (such as a certified marriage certificate or court order) and your current U.S. passport book
and/or passport card, along with this completed form to the address listed on page 2 of the instructions.
Current Name Last
First Middle
Was your identifying information printed
incorrectly in your U.S. passport book or passport
card?
Name Last
If yes, please complete the information as it should
appear, and check only the box(s) next to the
field(s) to be corrected.
First
Middle
Date of Birth (mm/dd/yyyy) Sex
M
F
Place of Birth (State or Country)
Please submit evidence documenting your correct identifying information (such as a certified marriage certificate or birth certificate) and your
current U.S. passport book and/or passport card, along with this completed form to the address listed on page 2 of the instructions.
Was your most recent U.S. passport limited for
one year or less?
Yes No
If yes, please submit evidence of your United States
citizenship (such as a government-issued birth
certificate) and/or evidence of your identity (such as a
driver's license or a state issued identification (ID)
card).
Note: To complete a limited U.S. passport book replacement, your submitted U.S.
passport book must not be expired. Passport books limited in validity because of
multiple losses, damages, or mutilations cannot be extended.
Please be sure to enclose your U.S. passport book along with this application to the
address listed on page 2 of the instructions.
Yes No
Yes No
Cell
Work
Home
* DS 5504 C 11 2013 2 *
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