DS-4085 Application for additional VISA Pages or Miscellaneous P

APPLICATION FOR ADDITIONAL VISA PAGES
OR MISCELLANEOUS PASSPORT SERVICES
PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS.
Date of Application:

FOR INFORMATION, QUESTIONS, AND INQUIRIES:
Please visit our website at travel.state.gov. In addition, 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 M–F 6AM–12 Midnight Eastern Time
(excluding federal holidays). Automated information is available 24/7.

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

ROUTINE SERVICE
MAIL THIS FORM TO:

EXPEDITED SERVICE (Additional Fee)
MAIL THIS FORM TO:

National Passport Processing Center
Post Office Box 90106
Philadelphia, PA 19190-0106

National Passport Processing Center
Post Office Box 90906
Philadelphia, PA 19190-0906

IS THERE A FEE ASSOCIATED WITH THIS FORM AND
HOW WILL MY NEW PASSPORT BOOK BE MAILED BACK TO ME?
•
•
•

There is no fee associated with the use of this form. Your U.S. passport book will be returned to you by priority mail.
SPECIAL POSTAGE SERVICE: If you desire that your passport book be sent using a special postage service (overnight mail, special delivery,
etc.) include the appropriate postage fee on the check.
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 the 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.
NOTE: The Passport Center will not mail a passport book to a private address outside the United States.
NOTE: If you choose to provide your e-mail address in Item #8 on this application, Passport Services will only use that information to
contact you in the event there is a problem with your application or if you need to provide additional information to us.

NOTICE TO APPLICANTS RESIDING ABROAD
United States citizens residing abroad CANNOT submit this form to the Passport Facility listed on Instruction Page
2. Such applicants should contact the nearest United States 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 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 therein or of the passport regulations is
punishable by fine and/or imprisonment under 18 USC 1544. All statements and documents are subject to verification.
DS–4085
XX-XXXX

Instruction Page 1 of 3

FEDERAL TAX LAW
Section 6039E of the Internal Revenue Code (26 U.S.C. 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 Making Payment by Check
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
31 U.S.C. 7701 requires persons “doing business” with a federal agency to provide their social security numbers to that agency. Because
the Department of State collects fees for the provision of passport services to you, you are considered a person “doing business” with the
Department. Passport service fees are established by law and regulation (see 22 U.S.C. 214, 22 CFR 22.1, and 22 CFR 51.61–66) 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
In addition to reporting your Social Security Number to Treasury and using it in connection with debt collection, the Department checks Social
Security Numbers against lists of persons ineligible or potentially ineligible to receive a U.S. passport.

PAPERWORK REDUCTION STATEMENT
You are not required to provide the information requested on this form unless the form displays a currently valid OMB number. We try to
create forms and instructions that can be easily understood. Often this is difficult to do because our citizenship laws are very complex. The
estimated burden time for this information collection is 20 minutes, which includes the time required to search existing data sources, gather
the necessary data, complete and review this form, and provide and submit the form and any additional information required. If you have
comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we would be happy to hear from you.
You can write to us at: U.S. Department of State (A/ISS/DIR) Washington, DC 20520.

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 statement. 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.
DS–4085

Instruction Page 2 of 3

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.

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 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 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 State Department has begun issuing a new type of passport book containing an embedded electronic chip and called an “Electronic
Passport”. The new 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 new passport book
to carry a duplicate electronic copy of all information from the data page. The new 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 new passport book provides for faster clearance through some of the port–of–entry
processes.
The new passport book does 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, which protects the data on the chip
from unauthorized reading.
The cover of the new 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.

DS–4085

Instruction Page 3 of 3

APPLICATION FOR ADDITIONAL VISA PAGES
OR MISCELLANEOUS PASSPORT SERVICES

OMB APPROVAL NO. 1405-0159
EXPIRATION DATE: XX-XXXX
ESTIMATED BURDEN: 20 MIN

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 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 therein or of the passport regulations is punishable by fine and/or
imprisonment under 18 USC 1544. All statements and documents are subject to verification.

1. Name Last

First & Middle

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

4. Place of Birth (City & State or City & Country as it is presently known)

3. Sex
M

5. Social Security Number

-

F

6. Mailing Address: Street/RFD # or P.O. Box

Apartment or unit #

City

State

Zip Code (Zip + 4 if known)

In Care Of or Country, if applicable

8. Email Address (Optional)

7. Contact Phone Number

-

-

Home
Work

-

Cell

10. Permanent Address: Street/RFD # (No P.O. Box)

9. Current Passport Number

Issue date (mm/dd/yyyy)

City

State

11. Additional Contact Phone Number

12. Occupation
Home
Work

Apartment or unit #

Zip Code

13. Employer

Cell
_________

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 or unit #

City
City

State

Zip Code

Phone Number

Relationship

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

Length of Trip

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 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.
x ____________________________________________________
Applicant’s Signature - age 16 and older

This section for
issuing office only

x ____________________________________________________
Parent’s/Legal Guardian’s Signature (if identifying minor)

_________________________________________________
Date

EF________
DS-4085 XX-XXXX

Postage________

Other________
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