Ds 4085 Form – Fill Out and Use This PDF

APPLICATION FOR ADDITIONAL VISA PAGES

OR MISCELLANEOUS PASSPORT SERVICES

PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS

Date of Application:__________________________

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 hours a day, 7 days a week.

HOW DO I APPLY FOR ADDITIONAL VISA PAGES?

1.Complete, sign, and date this form.

2.Send this form with your valid U.S. passport book and your fee for additional visa pages. Please visit our website at travel.state.gov for detailed information regarding current fees.

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 non-refundable.

NOTE: Because of the sensitivity of the enclosed documents, Passport Services recommends using trackable mailing service when submitting your application.

MAIL FORM TO:

FOR ROUTINE SERVICE:	FOR EXPEDITED SERVICE (Additional Fee):
National Passport Processing Center	National Passport Processing Center
Post Office Box 90106	Post Office Box 90906
Philadelphia, PA 19190-0106	Philadelphia, PA 19190-0906

OVERNIGHT DELIVERY SERVICE: If you desire overnight delivery for the return of your passport, please include the appropriate fee with your application.

FASTER PROCESSING: For an additional fee, you may request expedited service. Please include this fee with your application, and mail to the appropriate address. Please write "Expedite" ON OUTER ENVELOPE WHEN MAILING. TO ENSURE MINIMAL PROCESSING TIME for expedited applications,

Passport Services recommends using overnight delivery when submitting the application AND including the appropriate postage fee for return overnight delivery for the completed passport book. Expedited service is available only in the United States. Please consult our website for updated fee information and processing times.

HOW WILL MY PASSPORT BOOK BE MAILED BACK TO ME?

Your U.S. passport book will be returned to you by priority mail. To check the status of your passport application online please visit travel.state.gov.

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 at 1-877-487-2778 or visit travel.state.gov.

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 the form to the domestic addresses listed above. 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 and/or 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 and/or 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 and/or imprisonment under 18 U.S.C. 1544. All statements and documents are subject to verification.

If you choose to provide your email address in Item #6 on this application, Passport Services may 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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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 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 returned for any reason or you dispute a passport fee charge to you 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 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 passport. An invalidated passport cannot be used for travel.

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 U.S. 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 U.S. 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 U.S. passport card. Anyone using the U.S. passport book or U.S. 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 U.S. 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 U.S. passport book or U.S. passport card for travel.

PROTECT YOURSELF AGAINST IDENTITY THEFT!

REPORT YOUR LOST OR STOLEN U.S. PASSPORT BOOK OR U.S. PASSPORT CARD!

For more information or to report your lost or stolen U.S. passport book or U.S. passport card by phone, call NPIC or visit our website at travel.state.gov.

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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: We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 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 entitlement to receive the passport service for which you are applying. The collection of the Social Security number will be used for identity/entitlement verification only and no other purpose unless authorized by law.

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 your identity or entitlement, result in processing delays or denial of your application.

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 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.

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 20 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: 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.

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APPLICATION FOR ADDITIONAL VISA PAGES

OMB CONTROL NO. 1405-0159

OR MISCELLANEOUS SERVICES

OMB EXPIRATION DATE: 10-31-2016

Please Print Legibly Using Black Ink Only

ESTIMATED BURDEN: 20 MIN

Attention: Read WARNING on page 1 of instructions

Please select the 48 page option only if you prefer to add 48 visa pages in lieu of the standard 24 extra pages to

your passport book. The larger book is appropriate for those who anticipate very frequent travel abroad during

the passport validity period, and is recommended for applicants who have required the addition of visa pages in

the past. NOTE: If pages have been added to your passport book previously, we may not be able to

accommodate your request.

48 Pages (non-standard)

VP1

VP2

DOTS Code

1. Name as Listed on Passport: Last

End. #

Exp.

First

Middle

2. Date of Birth

(mm/dd/yyyy)

3.

Sex

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

-

-

M

F

5. Social Security Number

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

7. Primary Contact Phone Number

-

-

@

-

-

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

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

Country, if outside the United States

9. Current Passport Number

10. Permanent

Address - If P.O. Box is listed under Mailing Address or if residence is different from Mailing

Apartment/Unit

Street/RFD # or URB

(No P.O. Box)

Issue date (mm/dd/yyyy)

City

State

Zip Code

11. Additional Contact Phone Number

12. Occupation (if age 16 or older)

13. Employer or School (if applicable)

Home

Cell

Work

14. 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

Apartment/Unit

City

State

Zip Code

Phone Number

Relationship

15. Travel Plans

Departure Date (mm/dd/yyyy)

Return Date (mm/dd/yyyy)

Countries to be visited

YOU MUST SIGN AND DATE THE APPLICATION 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 three 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 knowingly and willfully made false statements or included false documents in support of this application; 4) I have read and understood the warning on page one of the instructions to the application form.

Attached:

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