Department of State
STATEMENT OF NONRECEIPT OF PASSPORT
WARNING: False statements made knowingly and willfully in passport applications in affidavits or other supporting documents submitted therewith are punishable by fine and/or imprisonment under the provisions of 18 USC 1001 and/or 18 USC 1542.
Name (first)                  (middle)                      (last)        

         		Departure date:
Place previous application filed


 Date application filed
PRIVACY ACT STATEMENT
The information solicited on this form is authorized by, but not limited to, those statutes codified in Titles 8,18, and 22, United States Code, and all predecessor statutes whether or not codified, and all regulations issued pursuant to Executive Order 11295 of August 5,1966. The primary purpose for soliciting the information is to establish citizenship, identity and entitlement to issuance of a United States passport or related facility, and to properly administer and enforce the laws pertaining thereto.
The information is made available as a routine use on a need-to-know basis to personnel of the Department of State and other government agencies having statutory or other lawful authority to maintain such information in the performance of their official duties; pursuant to a subpoena or court order; and, as set forth in Part 6a, Title 22, Code of Federal Regulations. (See Federal Register, Volume 40, pages 45755, 45756, 47419, and 47420.)
Failure to provide the information requested on this form may result in the denial of a United States passport, related document or service to the individual seeking such passport, document or service.



I, the undersigned, certify that I filed an application for a passport
on the date and at the place shown above. I further attest that I have
not received the passport for which the application was filed.

I request that a passport be issued to me and certify that if the passport
previously applied for is received, I will immediately return it to the
Passport Office, Department of State, Washington, D.C. 20524



__________________________________________________
Signature


____________________________________________________
Date

Passport Office Use Only
Previous Passport Number

 Date Issued
Place Issued
 Date Mailed

 Special Postage, if used
(   ) SD        (   ) REGIS

FORM 5-76 DSP-86                                                                                                                                                                                      FORM APPROVED  OMB NO. 47-R0178

 

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