Application for A United States Passport
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 conspi ring to overthrow, put down, or to destroy by force, the government of the United States.
Furthermore, I ha ve no t been convicted o f a federa l or state d rug offense or convicted of a "sex tourism" crimes statute, and I am not the subject o f
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: Collection of this in formation is authorized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E, Section 236 of the Admiral
James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001; 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 eligibility to be issued a U.S. p assport. Your Socia l Security number is
requested in order to verify your identity. Failure to provide your Social Security number on this form may delay processing of your application.
ROUTINE USES : This information may be disclosed to another domestic governm ent agency, a private contractor, a foreign government a gency,
or to a private person or private employer in acco rdan ce with certain approved routine uses. These routine uses include, but a re not li mited t o , 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 an d the other informa tion on this form is voluntary, but failure to provide the in formation o n
this form may, given the form's purpose of verification of identity and entitlement to a U.S. passport, result in processing delays or denial of the
Failure to provide your Social Security number may also subject you to a penalty enforced by the Internal Revenue Service, as described in the
Federal Tax Law section of the instructions to this form. Your Social Security number will be provided to the Department of the Treasury and may
be used in connection with debt collection, among other purposes as authorized and generally described in this section. Providing your Social
Security number and other information requested on this form is otherwise voluntary.
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
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.
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this co llection of informa tion is estima ted to average 95 minute s 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 comme nts 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.
Instruction Page 4 of 4
Application for A United States Passport PDF
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