Application for A U.S. Passport Name Change, Data Correction, And Limited Passport Book Replacement

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;

My identifying information in my most recent U.S. passport book and/or U.S.

passport card was printed incorrectly;

My most recent, full-fee U.S. passport book was limited in validity, and was issued

less than one year ago.

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 LIM ITED PASSPORT BOOK REPLACEMENT

PLEASE DET ACH 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

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 Nation al Passport Information Center for further information.

Yes

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 [email protected]

. 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 THI S 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!

Yes

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