U.S. Department of State
STATEMENT REGARDING A VALID LOST OR STOLEN U.S. PASSPORT BOOK AND/OR CARD
OMB Control No. 1405-0014
Expiration Date:
Estimated Burden: 5 Minutes
Page 2 of 2 DS-64
IMPORTANT NOTICE
A U.S. national may not normally bear more than one valid or potentially valid U.S. passport book and/or card at a time. Therefore, a statement is required when
applying for a new U.S. passport if the previously valid or potentially valid passport is not submitted. Your statement must detail Zhy the previous valid U.S. passport
cannot be presented. The information you provide on this form will be placed into the Consular Lost and Stolen Passport System, which is designed to prevent the
misuse of all reported valid lost or stolen U.S. passports. If more than one valid U.S. passport previously issued to you was lost or stolen, your replacement passport
may be limited in validity. ONCE REPORTED, THE VALID LOST OR STOLEN PASSPORT IS ELECTRONICALLY CANCELLED AND CANNOT BE USED FOR
TRAVEL. Anyone (including the bearer) traveling on a reported lost or stolen passport may be detained upon entering the United States. Should you locate the passport
after reporting it lost or stolen, submit it for cancellation to the Consular Lost and Stolen Passport Unit (CLASP). See page one of this form for contact information.
Please select the document (or documents) that you are reporting and its status.
Valid U.S. Passport Book
Lost Stolen
Valid U.S. Passport Card
Lost Stolen
Are you submitting this form in connection with an application for a new U.S. passport book and/or card? Yes No
Last Name First Name Middle Name
Has your name changed since the passport was issued? If yes, state the name in which the YDOLG lost or stolen passport was issued.
Date of Birth (mm-dd-yyyy) Place of Birth (City & State if in U.S. or City & Country) Social Security Number
Current Address (Street, City, State, and ZIP Code or Country, if outside the U.S.)
Telephone Number Alternative Telephone Number Email Address
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Explain in detail how your valid U.S. passport book/card was lost or stolen. Include a photocopy of the valid passport book/card if available.
Explain where the loss or theft occurred. Provide the address, if known (City and State, if in the U.S., or City and Country as it is presently known)
On what date was your valid U.S. passport book/card lost or stolen (mm-dd-yyyy)? If unknown, when was the last time you remember it being in your possession?
Did you file a police report? (If yes and the report is available, please submit a copy.) Yes No
List your valid lost or stolen U.S. Passport Book, if known: List your valid lost or stolen U.S. Passport Card, if known:
Number Issue Date
(mm-dd-yyyy)
Number Issue Date
(mm-dd-yyyy)
Have you had any other valid U.S. passport book/card lost or stolen? Yes No If yes, how many passports? Approximate date(s)?
(mm-dd-yyyy)
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I, the undersigned, declare under penalty of perjury all of the following: 1) that I have read and understDQG the warning on page one of this form; 2)
the information provided 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 the passport ERRN and/or passport card to Passport Services at the address on page one of
WKLV form or to the nearest U.S. passport agency, U.S. embassy or U.S. consulate if abroad, and I will not attempt to use it.
Applicant's Legal Signature - age 16 or older Date (mm/dd/yyyy)
Mother/Father/Parent/Guardian Legal Signature if identifying minor under age 16 Date (mm/dd/yyyy)
Mother/Father/Parent/Guardian Legal Signature if identifying minor under age 16 Date (mm/dd/yyyy)
Both parents or guardians of a child younger than 16 years old must sign and provide a front and back photocopy of ID when submitting this form on the child's behalf unless one
parent or guardian has sole authority to obtain a passport pursuant to 22 C.F.R. 51.28. If there is sole authority, include a copy of a supporting document with this form, such as a court order
proving sole legal custody or form DS-5525, Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor Under Age 16.
Please Print Legibly RU 7\SH Using Black Ink Only.
Did you file a police report? (If yes and the report is available, please submit a copy.) Yes No
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