APPLICATION FOR A U.S. PASSPORT
PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS
I applied:

Place:
Date:
FOR 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 NPIC@state.gov. Customer
Service Representatives are available Monday-Friday 8:00a.m.-10:00p.m. Eastern Time (excluding federal holidays.) Automated information is available 24/7.
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.

APPLICANTS WHO HAVE HAD A PREVIOUS U.S. PASSPORT BOOK AND/OR U.S. PASSPORT CARD
If your most recent passport book and/or passport card was issued less than 15 years ago and you were over 16 years old at the time of issuance, you may be eligible to use Form DS-82. To determine your eligibility, please visit travel.state.gov, or contact NPIC. Address any requests for the addition of visa pages to a passport agency or a U.S. consulate or embassy abroad. In advance of your departure, check for any visa requirements with consular officials of the countries you will be visiting.

SPECIAL REQUIREMENTS FOR CHILDREN
 AS DIRECTED BY PUBLIC LAW 106-113 AND 22 CFR 51.28:
To submit an application for a child under age 16 both parents or the child's legal guardian(s) must appear and present the following:
- Evidence of the child's U.S. citizenship
- Evidence of the child's relationship to parents/guardian(s), AND
- Parental/guardian identification.
IF ONLY ONE PARENT APPEARS, YOU MUST ALSO SUBMIT ONE OF THE FOLLOWING:
- Second parent's notarized written statement or DS-3053 (including the child's full name and date of birth) consenting to the passport issuance for the child.
Statement can not be more than 3 months old and must come with a photocopy of the front and back side of the second parent's identification, OR
- Second parent’s death certificate if second parent is deceased, OR
- Primary evidence of sole authority to apply, OR
- A written statement or DS-3053 (made under penalty of perjury) explaining in detail the second parent's unavailability.
 AS DIRECTED BY REGULATION 22 CFR 51.21 AND 51.28:
- Each minor child applying for a passport book and/or passport card must appear in person.

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.
WHAT TO SUBMIT WITH THIS FORM:
1.
2.
3.
4.

PROOF OF U.S. CITIZENSHIP (Evidence of U.S. citizenship that is not damaged, altered, or forged will be returned to you.)
PROOF OF IDENTITY (You must present your original identification AND submit a photocopy of the front and back side with your passport application.)
RECENT COLOR PHOTOGRAPH (Photograph must meet passport requirements – full front view of the face and 2x2 inches in size.)
FEES (Please visit our website at travel.state.gov for current fees.)

See page 2 of the instructions for detailed information on the completion and submission of this form.
WHERE TO SUBMIT THIS FORM:
Please complete and submit this application in person to one of the following acceptance agents: a clerk of a federal or state court of record or a judge or clerk of a probate court accepting applications; a designated municipal or county official; a designated postal employee at an authorized post office; an agent at a passport agency (by appointment only); or a U.S. consulate official at a U.S. embassy or consulate, if abroad. To find your nearest acceptance facility, visit travel.state.gov or contact the National Passport Information Center.
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 USC 1001, 18 USC 1542, and/or 18 USC
1621. Alteration or mutilation of a passport issued pursuant to this application is punishable by fine and/or imprisonment under the provisions of
18 USC 1543. The use of a passport in violation of the restrictions contained herein or of the passport regulations is punishable by fine and/or imprisonment under 18 USC 1544. All statements and documents are subject to verification.
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Instruction Page 1 of 4

1. PROOF OF U.S. CITIZENSHIP
APPLICANTS BORN IN THE UNITED STATES: Submit a previous U.S. passport or certified birth certificate. Passports that are limited in validity will need to be supplemented by other evidence. A birth certificate must include your full name, date and place of birth, sex, date the birth record was filed, the seal or other certification of the official custodian of such records (state, country, or city/town office), and the full names of your parent(s).
- If the birth certificate was filed more than 1 year after the birth: It must be supported by evidence described in the next paragraph.
- If no birth record exists: Submit a registrar's notice to that effect. Also, submit a combination of the following evidence: an early baptismal or circumcision certificate, hospital birth record, early census, school, medical, or family Bible records, or newspapers or insurance files. Notarized affidavits of persons having knowledge of your birth may be submitted in addition to some of the records listed above. Evidence should include your given name and surname, date and/or place of birth, and the seal or other certification of the office (if customary) and the signature of the issuing official. Visit travel.state.gov for details.
APPLICANTS BORN OUTSIDE THE UNITED STATES: Submit a previous U.S. passport, Certificate of Naturalization, Certificate of Citizenship, Report of Birth Abroad, or evidence described below:
- If you Claim Citizenship through Naturalization of Parent(s): Submit the Certificate(s) of Naturalization of your parent(s), your foreign birth certificate (and official translation if the document is not in English), and proof of your admission to the United States for permanent residence.
- If you Claim Citizenship through Birth Abroad to One U.S. Citizen Parent: Submit a Consular Report of Birth (Form FS-240), Certification of Birth (Form DS-1350 or FS-545), or your foreign birth certificate (and official translation if the document is not in English), proof of citizenship of your parent, your parents' marriage certificate, and an affidavit showing all of your U.S. citizen parents' periods and places of residence/physical presence in the United States and abroad before your birth.
- If you Claim Citizenship through Birth Abroad to Two U.S. Citizen Parents: Submit a Consular Report of Birth (Form FS-240), Certification of Birth (Form DS-1350 or FS-545), or your foreign birth certificate (and official translation if the document is not in English), parents' marriage certificate, proof of your parents' citizenship, and an affidavit showing all of your U.S. citizen parents' periods and places of residence/physical presence in the United States and abroad before your birth.
- If you Claim Citizenship through Adoption by a U.S. Citizen Parent(s): Submit evidence of your permanent residence status, full and final adoption, and your U.S. citizen parent(s) evidence of legal and physical custody. (NOTE: Acquisition of U.S. citizenship for persons born abroad and adopted only applies if the applicant was born on or after
02/28/1983.)
ADDITIONAL EVIDENCE: You must establish your citizenship to the satisfaction of the acceptance agent and Passport Services. We may ask you to provide additional evidence to establish your claim to U.S. citizenship.
NOTE: You may receive your newly issued document and your returned citizenship evidence in two separate mailings. If you are applying for both a passport book and passport 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 issued passport card.

2. PROOF OF IDENTITY
You may submit items such as the following containing your signature AND a photograph that is a good likeness of you: previous or current U.S. passport book; previous or current
U.S. passport card; driver's license (not temporary or learner's license); Certificate of Naturalization; Certificate of Citizenship; military identification; or federal, state, or municipal government employee identification card. Temporary or altered documents are not acceptable.
You must establish your identity to the satisfaction of the acceptance agent and Passport Services. We may ask you to provide additional evidence to establish your identity. If you have changed your name, please see travel.state.gov for instructions.
IF YOU CANNOT PROVIDE DOCUMENTARY EVIDENCE OF IDENTITY as stated above, you must appear with an IDENTIFYING WITNESS who is a U.S. citizen, non-citizen
U.S. national, or permanent resident alien who has known you for at least 2 years. Your witness must prove his or her identity and complete and sign an Affidavit of Identifying
Witness (Form DS-71) before the acceptance agent. You must also submit some identification of your own.

3. 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 a 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 not be worn in passport photographs. Any 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 at travel.state.gov for details and information.

4. FEES
 If you are sixteen years of age or older: Your passport will be valid for 10 years from the date of issue except where limited by the Secretary of State to a shorter period. (See information below about the additional cost for expedited service.)
 If you are under sixteen years of age: Your passport will be valid for 5 years from the date of issue except where limited by the Secretary of State to a shorter period. (see information below about the additional cost for expedited service.)
BY LAW, THE PASSPORT FEES ARE NON-REFUNDABLE. PLEASE VISIT OUR WEBSITE AT TRAVEL.STATE.GOV FOR CURRENT FEES.
 The passport processing, execution, and security fees may be paid in any of the following forms: Checks (personal, certified, or traveler's) with the applicant's full name and date of birth printed on the front; major credit card (Visa, Master Card, American Express, and Discover); bank draft or cashier's check; money order (U.S. Postal, international, currency exchange), or if abroad, the foreign currency equivalent, or a check drawn on a U.S. bank. All fees should be payable to the "Department of State" or if abroad, the appropriate U.S. embassy or U.S. consulate. When applying at a designated acceptance facility, the execution fee will be paid separately and should be made payable to the acceptance facility. NOTE: Some designated acceptance facilities do not accept credit cards as a form of payment.
 For faster processing, you may request expedited service. Please include the expedite fee in your payment. Our website contains updated information regarding fees and processing times for expedited service. Expedited service is available only in the United States.
 If you desire OVERNIGHT DELIVERY SERVICE for the return of your passport, please include the appropriate fee with your payment.
 An additional fee will be charged when, upon your request, the U.S. Department of State verifies issuance of a previous U.S. passport or Consular Report of Birth Abroad because you are unable to submit evidence of U.S. citizenship.
 For applicants with U.S. government or military authorization for no-fee passports, no fees are charged except the execution fee when applying at a designated acceptance facility.
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 address" then you must put the name of the person and mark it as "In Care Of." If your mailing address changes prior to receipt of your new passport, please contact the
National Passport Information Center.
If you choose to provide your email address in Item #6 on this application, Passport Services will use that information to contact you in the event there is a problem with your application or if you need to provide information to us.

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Instruction Page 2 of 4

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 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.

NOTICE TO CUSTOMERS APPLYING OUTSIDE A STATE DEPARTMENT FACILITY
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.
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 USC 214, 22 CFR 22.1, and 22 CFR 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 returned for any reason or you dispute a passport fee charge to your credit card, the 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. In addition, non-payment of passport fees may result in the invalidation of your passport. An invalidated passport cannot be used for travel.

OTHER USES OF SOCIAL SECURITY NUMBERS
Your Social Security Number will be provided to Treasury, used in connection with debt collection and checked against lists of persons ineligible or potentially ineligible to receive a U.S. passport, among other authorized uses.

PAPERWORK REDUCTION STATEMENT
Public reporting burden for this collection of information is estimated to average 85 minutes 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 comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State,
Washington, DC 20520-2202.

IMPORTANT NOTICE TO APPLICANTS WHO HAVE LOST OR HAD A PREVIOUS 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 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 PASSPORT BOOK OR PASSPORT CARD!
For more information or to report your lost or stolen passport book or passport card by phone, call NPIC or visit our website at travel.state.gov.

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Instruction Page 3 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/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 for 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 the information solicited on this form is authorized by Titles 8, 22, and 26 of the United States Code, and other applicable laws and regulations, including 22 USC 211a et seq.; 8 USC 1104; 26 USC 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 and private contractors to assist the U.S. Department of State in adjudicating passport applications and requests for related services, and for law enforcement, fraud prevention, border security, counterterrorism, litigation activities, and administrative 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 the Department of Homeland Security and private employers for employment verification purposes. For a more detailed listing of the routine uses to which this information may be put see the Department of State's Prefatory Statement of Routine Uses relative to the Privacy Act (Public Notice 6290 of July 15, 2008) and the listing of routine users set forth in the System of Records Notices for
Overseas Citizen Services Records (State-05) and Passport Records (State-26) published in the Federal Register.
Your social security numbers will be provided to the U.S. Department of Treasury and failure to provide it may subject you to a penalty, as described in the Federal Tax Law provision. It also may be used for identification verification for passport adjudication and 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 otherwise is voluntary, but failure to provide the information requested on this form may result in processing delays or the denial of your U.S. passport application.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Failure to provide the information requested on this form may result in Passport
Services' refusal to accept your application or result in the denial of a U.S. passport.

ELECTRONIC PASSPORT STATEMENT
The Department of State now issues a type of passport book containing an embedded electronic chip and called an "Electronic Passport". 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 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 port-of-entry areas where the electronic passport book can be read.

will appear in

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.

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Instruction Page 4 of 4

APPLICATION FOR A U.S. PASSPORT

OMB APPROVAL NO. 1405-0004
EXPIRATION DATE: 12-31-2013
ESTIMATED BURDEN: 85 MIN

Please Print Legibly Using Black Ink Only
Attention: Read WARNING on page 1 of instructions
Please select the document(s) for which you are applying:

X U.S. Passport Book

Both

U.S. Passport Card

The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions.

X 52 Page Book (Non-Standard)

28 Page Book (Standard)

Note: The 52 page option is for those who frequently travel abroad during the passport validity period and is recommended for applicants who have previously required the addition of visa pages.

1. Name Last
D

JACKSON
First

DP

DOTS Code
Exp.

Middle

MUSTAFA

ELISHA

2. Date of Birth (mm/dd/yyyy)

04

O

End. #

-

-

12

M

1986

-

66

-

F

DARBY, PA

X

6. Email Address (e.g. my_email@domain.com)

5. Social Security Number

177

3. Sex

4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.)

9125

MJACKSON412@HOTMAIL.COM

7. Primary Contact Phone Number

609

-

-

851

1996

8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.

P.O. BOX 9614
Address Line 2: Clearly label Apartment, Company, Suite, Unit, Building, Floor, In Care Of or Attention if applicable. (e.g. In Care Of - Jane Doe, Apt # 100)

City

State

Zip Code

PHILADELPHIA

PA

Country, if outside the United States

19131

9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed)
B.
10. Parental Information
Mother/Father/Parent - First & Middle Name

STAPLE

STAPLE

A.

CHARLEMA ADA

JACKSON

Date of Birth (mm/dd/yyyy)

Place of Birth

Sex
Male

09/20/1959

2" x 2"

2" x 2"

Last Name (at Parent's Birth)

PHILADELPHIA

Mother/Father/Parent - First & Middle Name

STAPLE

STAPLE

Submit a recent, color photograph

X Yes

Female

No

Last Name (at Parent's Birth)

WALTER EMMANUEL
Date of Birth (mm/dd/yyyy)

X

U.S. Citizen?

CAPPS
Place of Birth

Sex

X

Male
Female

U.S. Citizen?

X

Yes
No

CONTINUE TO PAGE 2

DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY AUTHORIZED AGENT
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 the reverse side of this application (unless explanatory statement is attached); 2) the statements made on the application are true and correct; 3) I have not knowingly and willfully made false statements or included false documents in support of this application; 4) the photograph submitted with this application 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.
Identifying Documents - Applicant or Mother/Father/Parent on Second Signature Line (if identifying minor)
Driver's License

x

Issue
Date

Exp.
Date

Place of
Issue

Passport

Applicant's Legal Signature - age 16 and older

Name

Military

x

Other

Mother/Father/Parent/Legal Guardian's Signature (if identifying minor)

ID No

Identifying Documents - Applicant or Mother/Father/Parent on Third Signature Line (if identifying minor)
Driver's License

x
Mother/Father/Parent/Legal Guardian's Signature (if identifying minor)

Passport

Acceptance Agent

Military

(Vice) Consul USA

Passport Staff Agent

Exp.
Date

ID No

Facility Name/Location
Facility ID Number
Signature of person authorized to accept applications

For Issuing Office Only

DS-11 12-2010

Place of
Issue

Name

Other

(Seal)

Issue
Date

Bk

Card

Execution

EF

Agent ID Number

Date

Postage

Other

* DS 11 B 12 2010 1 *
Page 1 of 2

Date of Birth (mm/dd/yyyy)

Name of Applicant (Last, First & Middle)

JACKSON, MUSTAFA ELISHA
11. Height

12. Hair Color

04/12/1986
14. Occupation (if age 16 or older)

13. Eye Color

5ft. 11in. Black

Brown

15. Employer or School (if applicable)

TRUTH OF LIFE MINISTRIES

PASTOR

16. Additional Contact Phone Numbers
Home
Work

Cell

Home
Work

17. Permanent Address - If P.O. Box is listed under Mailing Address or if residence is different from Mailing Address.
Street/RFD # or URB (No P.O. Box)

Cell

Apartment/Unit

1221 NORTH 56TH STREET
City

State

Zip Code

PA

PHILADELPHIA

19131

18. 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

CLAUDIA BOATWRIGHT

Apartment/Unit

5257 ARLINGTON STREET

City

State

Zip Code

Phone Number

Relationship

PHILADELPHIA

PA

19131

267-304-0856

GOD MOTHER

19. Travel Plans
Date of Trip (mm/dd/yyyy) Duration of Trip

Countries to be Visited

07/09/2012

COZUMEL, MEXICO

5 DAYS

20. Have you ever been married?

Yes

X

No

If yes, complete the remaining items in #20.

Full Name of Current Spouse or Most Recent Spouse

Date of Birth (mm/dd/yyyy)

Place of Birth

U.S. Citizen?
Yes

Date of Marriage
(mm/dd/yyyy)

Have you ever been widowed or divorced?

21. Have you ever applied for or been issued a U.S. Passport Book?
Name as printed on your most recent passport book

Yes

Status of your most recent passport book
Submitting with application

Stolen

Lost

In my possession (if expired)

22. Have you ever applied for or been issued a U.S. Passport Card?
Name as printed on your most recent passport card

Yes

Status of your most recent passport card
Submitting with application

Stolen

Lost

In my possession (if expired)

X No

Yes
No

No

Date (mm/dd/yyyy)

If yes, complete the remaining items in #21
Most recent passport book number

Date most recent passport book was issued or approximate date you applied (mm/dd/yyyy)

X

No

If yes, complete the remaining items in #22
Most recent passport card number

Date most recent passport card was issued or approximate date you applied (mm/dd/yyyy)

PLEASE DO NOT WRITE BELOW THIS LINE
FOR ISSUING OFFICE ONLY

Sole Parent
Name as it appears on citizenship evidence
Birth Certificate

SR

CR

City

Filed:

Report of Birth

240

545

1350

Filed/City:

Nat. / Citz. Cert.

Date/Place Acquired:

Passport

C/R

S/R

Per PIERS

Issued:

A#

#/DOI:

Other:
Attached:
P/C of ID

DS-11 12-2010

DS-3053

DS-64

Bio Quest

Citz W/S

DS-10

DS-86

DS-71

DS-60

* DS 11 B 12 2010 2 *
Page 2 of 2