EFTA00298132.pdf

U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS Date of Application: CAN I USE THIS FORM? Complete the checklist to determine your eligibility to use this form I can submit my most recent U.S. passport book andor U.S. passport card with this application. X Yes No I at least 16 old my most recent U.S. book was years when passport and/or passport card was issued. X Yes No I was issued my most recent U.S. passport book andror passport card less than 15 years ago. X Yes K No My most recent U.S. passport book andror U.S. passport card that I am renewing has not been lost. stolen. mutilated. or damaged. X Yes No My U.S. passport has not been limited from the normal ten year validity period due to passport damagermutilation. multiple passport thefts/losses, or noncompliance with 22 C.F.R. 51.41. (Please X Yes No refer to the back pages of your U.S. passport book for endorsement information.) I use the same name as on my recent U.S. passport book andror U.S. passport card. Yes K No —OR— I have had my name changed by marriage or court order and can submit proper documentation to reflect my name change. If you answered NO to any of the statements above, STOP - You cannot use this form! You must apply on application form DS-11 by making a personal appearance before an acceptance agent authorized to accept passport applications. Visit travel.state.gov to find your nearest acceptance facility. 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 U.S. 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 NOTE: YOUR NEW PASSPORT WILL HAVE A DIFFERENT PASSPORT NUMBER THAN YOUR PREVIOUS PASSPORT. INFORMATION, QUESTIONS, AND INQUIRIES 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 NPICOstate.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. 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. WARNING: False statements made knowingly and willfully in passport applications. including affidavits or other documents submitted to support this application. are punishable by fine andror 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 andor 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 andror 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. DS-82 08-2013 Instruction Page 1 of 4 EFTA00298132 WHAT DO I SEND WITH THIS APPLICATION FORM? • Your most recent U.S. passport book and/or card; • A certified copy of your marriage certificate or court order if your name has changed; • Fees; and • A recent color photograph. See below for more detailed information. 1. YOUR MOST RECENTLY ISSUED U.S. PASSPORT (BOOK AND/OR CARD FORMAT). • Submit your most recently Issued U.S. passport book and/or card. When submitting a U.S. passport book and/or card with this form, please verify that the document was issued at age 16 or older in your current name (or see item 4/2 below) and issued within the past 15 years. You are also eligible to use this form if you currently have a U.S. passport book andfor card that complies with the previously listed criteria, and would like to obtain a alternative product (U.S. passport book and/or card) for the first lime. However, you must submit the product you currently have (U.S. passport book andfor card) with this application. II your U.S. passport book and/or card has been lost, stolen, damaged. or mutilated. you must apply on the DS•11 application form as specified below. 2. A CERTIFIED MARRIAGE CERTIFICATE OR COURT ORDER. (PHOTOCOPIES ARE NOT ACCEPTED) • If the name you are currently using differs from the name on your most recent U.S. passport, you must submit a certified copy of your marriage certificate or court order showing the change of name. All documents will be returned to you by mail. 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. 3. THE CURRENT PASSPORT FEE. • Enclose the 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 nonrefundable. Please visit our website at fravel.state.uov for detailed information regarding current fees. OVFRNIGHT nFi IVFRY CFRVICF. If you desire overnight delivery service for the return of your U.S. passport. please 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 PROCFSSING TIMF for expedited passport book applications, Passport Services recommends using overnight delivery when submitting the application AND including the appropriate postage fee for return overnight delivery for the newly issued passport book. Expedited service is available only in the United States. Overnight return delivery is only available for passport books. Please visit kriggatate.aoy for updated information regarding fees. processing times. or to check the status of your passport application online. 4. 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 ir qj be worn in the passport photograph. My photograph retouched so that your appearance is changed is unacceptable. A snapshot, most vowing 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. Please visit our website at lravel.state.aoy for details and information. WHERE DO I MAIL THIS APPLICATION? FOR ROUTINE SERVICE: National Passport Processing Center Post Office Box 90155 Philadelphia, PA 19190-0155 FOR EXPEDITED SERVICE (Additional Fee): National Passport Processing Center Post Office Box 90955 Philadelphia, PA 19190-0955 Due to the sensitivity of the enclosed documents. Passoon Services recommends usino trackable maim service when subminino your application. 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 addrese, then you must put the name of the person and mark it as 'In Care Of.' II your mailing address changes prior to receipt of your new passport. please contact the National Passport Information Center (NPIC) at 1.877.487.2778 or visit traveLstate.aov. NOTE: You may receive your newly issued document and your returned citizenship evidence in separate mailings. If you are applying for both a passport book andfor card, you may receive three separate mailings: one with your returned citizenship evidence: one with your newly issued passport book, and one with your newly printed passport card. If you choose to provide your email address in Item k6 on this application, Passport Services may use that address to contact you in the event there is a problem with your application or if additional information Is required. DS•82 08.2013 Instruction Page 2 of 4 EFTA00298133 FEDERAL TAX LAW Section 6039E of the Internal Revenue Code (26 USC 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 U.S. Department of Treasury. If you tail 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. NOTICE TO CUSTOMERS APPLYING OUTSIDE A STATE DEPARTMENT FACILITY If you send us a check. it will be convened 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. REMITTANCE OF FEES 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 retumed 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 Department 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 U.S. passport book and/or card. An invalidated passport card cannot be used for travel. OTHER USES OF SOCIAL SECURITY NUMBER Your Social Security number will be provided to the U.S. Department of Treasury. used in connection with debt collection and checked against lists of persons ineligible or potentially ineligible to receive a U.S. passport book andfor card. among other authorized uses. 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. 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 U.S. PASSPORT BOOK OR PASSPORT CARD! For more information or to report your lost or stolen U.S. passport book or passport card by phone. call NPIC at: 1-877.487.2778 or visit our website at travel.state.aov. 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 one of your given names you list on item 1 of this form. DS-82 08.2013 Instruction Page 3 of 4 EFTA00298134 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: Collection of this information is authorized by 22 U.S.C. 211a et seq.: 8 U.S.C. 1104: 26 U.S.C. 6039E: 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. passport. Your Social Security number is requested in order to verity 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 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 identity and entitlement to a U.S. passport. result in processing delays or denial of the passport application. 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 bearers 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. 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 documentation 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. DS-82 08.2013 Instruction Page 4 of 4 EFTA00298135 r• .. 4, . V tir U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS °"maRcd-a hum°2° 1/44.e, OBS EXPIRADON DATE: I2-3I -20I6 Please Print Legibly Using Black Ink Only [STRIATED BURDEN: 40 MIN Attention: Read WARNING on page I of instructions Please select the docurnent(s) for which you are wilt: 0 U.S. Passport Book U.S. Passport Card Both The U.S. passport card is gal valid lor international air travel. Fe, nitre informaban see page 1 el insiruclims CI 28 Page Book (Standard) O 52 Page Book (Non•Standarcl) Note: The 52 page option is ler those who frequerdy travel abroad during the passport validlyperiod. and is recommended [flppltares who have previously required the midden el visa pages. 1. Name Last EPSTEIN First JEFFREY 2. Date of Birth (mmiddlyyyy) 01 20 1953 3. Sex IA F X Middle ED Lc) 1- 1, DP DOTS Code. End. # Exp. EDWARD 4. Place of Birth (City & Stare if in the U.S.. or City & Country as it is presently known.) NEW YORK, NY 5. Social Security Number 6. Email Address (o.g.. my email@domain.com) ■ 8. Mailing Address: Line I: StreetiRFD#. P.O. Box, or URB. JEEVACATION@GMAIL.COM 7. Primary Contact Phone Number 6100 RED HOOK QUARTER, B3 Address Line 2. Clearly label Apartment, Company. Suite. Unit. Building. Floor. In Care Of or Attention if applicable. (e.g.. In Cam O1- Jane Doe. Apt # 100) City ST THOMAS State Zip Code Country. if outside the United States VI 00802 9. List all other names you have used. (Examples: Birth Name. Maiden. Previous Marriage. Legal Name Change. Attach additional pages if needed) A. B. 10. Passport Book and/or Passport Card Information Your name as printed on your most recent U.S. passport book and/or passport card JEFFREY EDWARD EPSTEIN Most recent passport book number Issue date (mm/dckyyyy) 05/31/2016 Most recent passport card number Issue date (mm/dd/yyyy) 11. Name Change Information Complete if name is different than last U.S. passport book or passport card Changed by Marriage Changed by Court Order Place of Name Change (City/Stare) Date (mmldd/yyyy) Please submit a certified copy. (Photocopies are not accepted* CONTINUE TO PAGE 2 YOU MUST SIGN AND DATE THE APPUCATION IN THE DESIGNATED AREA BELOW 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 knoVingly and wilfully made false statements or included false documents in support of this application:4) the photograph submitted with this appication 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% Legal Signature FOR ISSUING OFFICE ONLY El PPT BK CORO PPT BK SIR 0 PPT CD C/R 0 PPT CD SfR O Marriage Certificate Date of MarriagelPiace Issued: O Cowl Order Date Filedtoun: From Toe 0 Other O Attached: 1111111 11111 Date 111101111111111 1111111 111 11 For Issuing Office Only —le Bk Fee Cd Fee EF Postage Other. DS SIB S2 DS-82 08-2013 Page 1 of 2 EFTA00298136 Name of Applicant (Last. First & Middle) Date of Birth (mni/ddlyyyy) EPSTEIN, JEFFREY EDWARD 01/20/1953 12. Height 13. Hair Color 14. Eye Color Sit. llin. GRAY BLUE 15. Occupation 16. Employer or School (if applicable) BANKER 17. Additional Contact Phone Numbers Home CO Work SOUTHERN TRUST COMPANY Home CO MA 18. Permanent Address: It P.O. Box is listed under Mailing Address or if residence is different from Mailing Address. StreehRED a or URB No P.O. Box) Apanment/Unit City State Zip Code 19. Emergency Contact • Provide the information of a person not traveling with you to be contacted in the event of an emergency. Name Address: Street/RFD # or P.O. Box DARREN INDYKE Orly State Zip Code Phone Number Relationship 20. Travel Plans Departure Date (mmiddryyyy) Return Date (min/cid yyyy) Countries to be visited 10/20/2016 10/25/2016 Apartment Unit ATTORNEY CANADA STOP! YOU HAVE COMPLETED YOUR APPLICATION BE SURE TO SIGN AND DATE PAGE ONE 1111111 DS-82 08-2013 Page 2 of 2 EFTA00298137