PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR

See Instruction Page 2 for Detailed Information

on the Completion and Submission of this form.

INCOMPLETE OR UNACCEPTABLE APPLICATIONS WILL DELAY THE ISSUANCE OF YOUR PASSPORT.

If you answered NO to any of the four statements above,

STOP - You cannot use this form!!!

You must apply on application form DS-11 by making a personal appearance before a passport agent,

postal clerk, or clerk of court authorized to accept passport applications.

U.S. Department of State

APPLICATION FOR A U.S. PASSPORT BY MAIL

DS-82

09-2005

Instruction Page 1 of 4

PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET

FOR YOUR RECORDS.

Date of Application:

CAN I USE THIS FORM?

Complete this checklist to determine your eligibility to use this form.

1. I can submit my most recent U.S. passport.

2. I was at least 16 years old when my most recent U.S. passport was issued.

3. I was issued my most recent U.S. passport less than 15 years ago.

4. I use the same name as on my most recent U.S. passport.

-- OR --

I have had my name changed by marriage or court order and can submit

proper documentation to reflect my name change.

Yes

Yes No

FOR INFORMATION, QUESTIONS, AND INQUIRIES:

Please visit our website at travel.state.gov. In addition, contact the National Passport Information

Center (NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by e-mail at [email protected].

Customer Service Representatives are available M-F, 8AM-8PM EST (excluding Federal holidays).

Automated information is available 24/7.

Yes

Yes No

NOTICE TO APPLICANTS RESIDING ABROAD

United States citizens residing abroad CANNOT submit this form to the passport facility listed on instructions page 2.

Such applicants should contact the nearest United States embassy or consulate for procedures to be followed when

applying overseas.

WHAT DO I NEED TO SEND WITH THE APPLICATION FORM?

1. Your most recent U.S. passport

. A marriage certificate or court order if your name has changed

3. Fee of $67 (If requesting expedited service, the total fee will be $127)

4. Two recent, color photographs

See below for more detailed information.

YOUR MOST RECENT U.S. PASSPORT. Issued at age 16 or older in your current name (or see item #2 below)

and issued within the past 15 years. If your U.S. passport is damaged, you must apply on the DS-11 application

form as specified below.

A MARRIAGE CERTIFICATE OR COURT ORDER. If the name you are currently using differs from the name on

your most recent passport, you must submit a marriage certificate or court order showing the change of name.

The name change document MUST bear the official seal of the issuing authority. Uncertified copies or notarized

documents cannot be accepted. All documents will be returned to you with your passport. 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) any clerk of a Federal, State or county court of record or an probate

court accepting passport applications; or (3) a Post Office which has been selected to accept passport

applications.

THE FEE OF $67. Enclose the $67 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 fee is non-refundable.

For faster processing, you may request expedited service. Expedited requests will be processed in three

workdays from receipt at a passport agency. The additional fee for expedited service is $60. Therefore, if you

choose to request expedited service the total cost of you U.S. passport will be $127. Expedited service is

available only in the United States.

If you desire SPECIAL POSTAGE SERVICE (overnight mail, special delivery, etc.), include the appropriate

postage fee on the check or include a pre-paid envelope.

TWO RECENT, COLOR PHOTOGRAPHS. Submit two color photographs of you alone, sufficiently recent to

be a good likeness of you (normally taken within the last six months), and 2x2 inches in size. The image size

measured from the bottom of the 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 photographs 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. They must be capable of withstanding a

mounting temperature of 225 Fahrenheit (107 Celsius). Photographs 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. Photographs retouched so that your appearance is changed are

unacceptable. Snapshots, most vending machine prints, and magazine or full-length photographs are

unacceptable. Digitized photos must meet the previously stated qualifications and will be accepted for use at

the discretion of Passport Services. (Visit our website for details.)

If you choose to provide your e-mail address in Item #15 on this application, Passport Services will only

use that information to contact you in the event there is a problem with your application or if you need to

provide additional information to us.

NOTE:

WHERE DO I MAIL THIS APPLICATION ?

DS-82

Instruction Page 2 of 4

DELIVERY - Other Than U.S. Postal Service:MAIL THIS FORM TO:

National Passport Processing

Post Office Box 371971

Pittsburgh, PA 15250-7971

FOR INQUIRIES CONTACT:

National Passport Information Center

1-877-487-2778

For TDD: 1-888-874-7793

E-mail: [email protected]

Website: travel.state.gov

Passport Services Lockbox

ATTN: Password Supervisor, 371971

500 Ross Street, Room 154-0670

Pittsburgh, PA 15262-0001

DS-82

Instruction Page 3 of 4

FEDERAL TAX LAW

Section 6039E of the Internal Revenue Code (26 U.S.C. 6039E) requires you to provide your Social Security Number

(SSN), if you have one, when you apply for a U.S. passport or renewal of a U.S. passport. If you have not been issued

a SSN, enter zeros in box #5 of this form. If you are residing abroad, you must also provide the name of the foreign

country in which you are residing. The U.S. Department of State must provide your SSN and foreign residence

information to the Department of Treasury. If you fail to provide the information, you are subject to a $500 penalty

enforced by the IRS. All questions on this matter should be directed to the nearest IRS office.

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.

NOTICE TO CUSTOMERS MAKING PAYMENT BY CHECK

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.

31 U.S.C. 7701 requires persons "doing business" with a federal agency to provide their security numbers to that

agency. Because the U.S. Department of State collects fees for the provision of passport services to you, you are

considered a person "doing business" with the Department. Passport service fees are established by law and

regulation (see 22 U.S.C. 214, 22 CFR 22.1, and 22 CFR 51.61-66) 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 you credit card, the U.S. Department of State

will take action to collect the delinquent fees from you under 22 CFR Part 34 and the Federal Claims Collection

Standards (see 31 CFR 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 Department will refer the

debt to the Department of Treasury for collection. Debt collection procedures used by 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.

PAYMENT OF FEES

In addition, non-payment of passport fees will result in the invalidation of your passport. An invalidated passport cannot

be used for travel.

In addition to reporting your Social Security Number to Treasury and using it in connection with debt collection, the

Department checks Social Security Numbers against lists of persons ineligible or potentially ineligible to receive a U.S.

passport.

OTHER USES OF SOCIAL SECURITY NUMBERS

PAPERWORK REDUCTION STATEMENT

You are not required to provide the information requested on this form unless the form displays a currently valid OMB

number. We try to create forms and instructions that can be easily understood. Often this is difficult to do because our

citizenship laws are very complex. The estimated burden time for this information collection is 40 minutes, which

includes the time required to search existing data sources, gather the necessary data, complete and review this form,

and provide and submit the form and any additional information required. If you have comments concerning the

accuracy of this time estimate or suggestions for making this form simpler, we would be happy to hear from you. You

can write us at: U.S. Department of State (A/RPS/DIR), Washington, DC 20520.

IMPORTANT NOTICE TO APPLICANTS WHO HAVE LOST OR HAD A PREVIOUS PASSPORT STOLEN

A United States citizen may not normally bear more than one valid or potentially valid U.S. passport at a time. It

therefore is necessary to submit a statement with an application for a new U.S. passport when a previous valid or

potentially valid U.S. passport cannot be presented with an application for a new passport. Your statement must detail

why the previous U.S. passport cannot be presented.

The information you provide regarding your lost or stolen U.S. passport 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. Anyone using

the passport book reported as lost or stolen may detained upon entry into the United States. Should you locate the U.S.

passport 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 for travel.

PROTECT YOURSELF AGAINST IDENTITY THEFT - REPORT YOUR LOST OR STOLEN PASSPORT!

For more information or to report your lost or stolen passport by phone, call NPIC or visit our website at travel.state.gov.

DS-82

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, 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.

PRIVACY ACT STATEMENT

AUTHORITIES: Collection of the information solicited on this form is authorized by Titles 8, 22, and 26 of the United

States Code, whether or not codified, including specifically 22 U.S.C. 211a et seq.; 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 CFR parts 50 and 51.

PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to

issuance of a U.S. passport.

ROUTINE USES: The information solicited on this form may be made available as a routine use to other government

agencies to assist the U.S. Department of State in adjudicating passport applications and requests for related services,

and for law enforcement and administration purposes. The information may be made available to foreign government

agencies to fulfill passport control and immigration duties. The information may also be provided to foreign government

agencies, international organizations and, in limited cases, private persons and organizations to investigate, prosecute,

or otherwise address potential violations of law or to further the Secretary's responsibility for the protection of U.S.

citizens and non-citizen nationals abroad. The information may be made available to private U.S. citizen 'wardens'

designated by the U.S. embassies and consulates. For a more detailed listing of the routine uses to which this

information may be put, see the Prefatory Statement of Routine Uses and the listing of routine users set forth in the

system descriptions for Overseas Citizen Services Records (State-05) and Passport Records (State-26) published in the

Federal Register.

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: With the exception of your Social Security Number

(see Federal Tax Law statement on Instruction Page 3), you are not legally required to provide the information

requested on this form. However, failure to do so may result in Passport Services' refusal to accept your application or

result in the denial of a U.S. passport.

ELECTRONIC PASSPORT STATEMENT

The U.S. Department of State will begin issuing a new type of passport containing an embedded electronic chip and

called an "Electronic Passport". The new passport will continue to be proof of the bearer's United States citizenship and

identity, and will look and function in the same way as a passport without a chip. The addition of an electronic chip in

the back cover will enable the new passport to carry a duplicate electronic copy of all information from the data page.

The new passport will be usable at all ports-of-entry, including those that do not yet have electronic chip readers.

Use of the electronic format will provide the traveler the additional security protections inherent in chip technology.

Moreover, when used at ports-of-entry equipped with electronic chip readers, the new passport will provide for faster

clearance through some of the port-of-entry processes.

Issuance of this new passport will be phased in during an 18-month period. It is expected that by late 2006 nearly all

U.S. passports will be issued in this new format. The new passport will not require special handling or treatment, but like

previous versions should be protected from extreme bending and from immersion in water. The electronic chip must be

read using specially formatted readers, and is not susceptible to unauthorized reading.

The cover of the new passport will be printed with a special symbol representing the embedded chip. The symbol

will appear in port-of-entry areas where the electronic passport can be read.

NOTICE TO APPLICANTS FOR OFFICIAL, DIPLOMATIC, OR NO-FEE PASSPORTS

You may use this application if you meet all of the provisions listed on Instruction Page 2, 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.

4. Place of Birth

(City & State OR City & Country)

Street / RFD # OR Post Office Box

2" x 2"

City

STOP

You must submit your most recent U.S. passport with this form! If you cannot submit your most

recent U.S. passport, apply on Form DS-11, Application For A U.S. Passport.

16. Passport Information

APPLICATION FOR A U.S. PASSPORT BY MAIL

U.S. Department of State

WARNING: False statements made knowingly and willfully in passport applications,

including affidavits or other supporting documents submitted therewith, are punishable

by fine and/or imprisonment under 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.

DS-82

09-2005

Page 1 of 2

1. Name of Applicant

OMB APPROVAL NO. 1405-0020

EXPIRATION DATE: 08/31/2008

ESTIMATED BURDEN: 40 Minutes

(See Instruction Page 3)

11. Mail My New Passport To:

( )

Name in which most recent passport was issued

Most recent U.S. passport number Issue date of most recent U.S. passport

When completing this form, PRINT IN BLUE OR BLACK INK ONLY

2. Date of Birth

(mm-dd-yyyy)

3. Sex

Male

Female

5. Social Security Number

(See Federal Tax Law Notice on Instruction Page

Last Suffix (Jr., Sr., III)

First Middle

Feet Inches

6. Height 7. Hair Color 8. Eye Color

9. Occupation 10. Employer

12. Permanent Address or Residence (If same as mailing address write "Same As Above")

Street / RFD # (DO NOT LIST P.O. BOX)

Apartment #

City

State

ZIP Code

Apartment #

State

ZIP Code

In Care of (If Applicable)

Country (If Outside the U.S.)

15. E-Mail Address (Optional)13. Home Telephone (Include Area Code) 14. Business Telephone (Include Area Code)

Issue

Date

R D O DP

End. #

Exp.

Submit two recent,

color photographs

DS-82

Page 2 of 2

NAME OF APPLICANT (Last, First, Middle) Date of Birth (mm-dd-yyyy)

17. Travel Plans

Date of Trip (mm-dd-yyyy) Countries to be VisitedLength of Trip

18. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency.

Name

State ZIP Code

19. Oath & Signature

Telephone E-Mail Address (Optional) Relationship

( )

Apartment #

Street / RFD #

Applicant's Signature

Date (mm-dd-yyyy)

DO NOT WRITE BELOW - FOR PASSPORT SERVICES USE ONLY - DO NOT WRITE BELOW

Evidence of Name Change

Marriage Certificate

Court Order

Document Issue Date

Place of Issue

Issuing Office/Court

Previous Name

Current Name

APPLICATION APPROVAL

FEE EXEC. EF OTHER

City

You must sign and date this application in the designated area below!

NOTE:

I declare under penalty of perjury that I am a United States citizen (or non-citizen national) and have not, since acquiring United State citizenship (or

U.S. nationality), performed any of the acts listed under "Acts or Conditions" on the reverse of this application form (unless explanatory statement is

attached). I declare under penalty of perjury that the statements made on this application are true and correct.