DS-5504
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.
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.
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.