Date Issued

A U.S. citizen may not normally bear more than one valid or potentially valid U.S. passport book and one valid U.S.
passport card at a time. You have 90 days from the date that your passport document(s) was issued to report that you
have not yet received it in the mail. If you do not report the non-receipt of your U.S. passport document(s) within
90 days of the issue date, you will be required to reapply and submit the full passport fee. To check the status
of your U.S. passport application please visit travel.state.gov or contact our National Passport Information Center
(NPIC) 1-877-487-2778 (TDD: 1-888-874-7793).
Date Mailed
(mm-dd-yyyy)
Place Issued
Primary Telephone Number
Date Mailed
Middle Name Last Name First Name
Date of Birth (mm-dd-yyyy)
DS-86
08-2012
Page 1 of 2
I, the undersigned, certify that I have not received the U.S. passport book and/or U.S. passport card for which I applied for. I declare under penalty
of perjury that the statements made on this form are true and correct. I request that a new U.S. passport book and/or U.S. passport card be issued to
me and certify that if I receive the U.S. passport book and/or U.S. passport card previously applied for, I will immediately contact the National
Passport Information Center at 1-877-487-2778 (TDD: 1-888-874-7793) and return the recovered passport to the U.S. Department of State.
PASSPORT OFFICE USE ONLY
Parent's/Legal Guardian's Signature
U.S. Department of State
OMB Control No.: 1405-0146
OMB Expiration Date: 07-31-2014
Estimated Burden: 5 Minutes
STATEMENT OF NON-RECEIPT OF A PASSPORT
Was the passport mailed to the correct mailing address? Yes
Previous U.S. Passport Card Number
Place Issued Special Postage, If Used (mm-dd-yyyy)
Apartment /Unit
City ZIP Code
Please select the document(s) which you are reporting.
U.S. Passport Book U.S. Passport Card
Protect yourself against identity theft! Report the non-receipt of your passport book or passport card!
Street Address
State
Date (mm-dd-yyyy)
Previous U.S. Passport Book Number Date Issued
Special Postage, If Used (mm-dd-yyyy)
(mm-dd-yyyy)
Secondary Telephone Number
Mailing Address:
No Was delivery confirmed? No Yes
UPS Fed Ex Vendor: DHL USPS Tracking Number:
Applicant's Signature - age 16 and older
IMPORTANT NOTICE
This application must be accompanied with a clear photocopy of an identification containing your photo.
The information that you provide on the DS-86, Statement of Non-Receipt of a Passport, will be placed into the
Consular Lost or Stolen Passport System. Anyone using the U.S. passport book or U.S. passport card reported on
the DS-86, including yourself, may be detained. Should you receive the document you reported as non-received at a
later time, report it as found and submit it for cancellation. It has been invalidated. You may not use it for travel.
See page two of this form for additional information.
PAPERWORK REDUCTION ACT STATEMENT
PRIVACY ACT STATEMENT
WARNING
HOW TO USE THIS FORM
False statements made knowingly and willfully in passport applications or in affidavits or other
supporting documents submitted therewith are punishable by fine and/or imprisonment under 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
U.S. 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 U.S. 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.
DS-86 Page 2 of 2
This form must be mailed to the passport agency that originally processed your
application. To obtain the address of that agency please call the National
Passport Information Center at 1-877-487-2778 (TDD: 1-888-874-7793).

AUTHORITIES: Collection of the information solicited on this form is authorized by Titles 8 and 22 of
the United States Code, and other applicable laws and regulations, including 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: The primary purpose for soliciting the information is to establish the need for a
replacement U.S. passport to customers who have not received the passport for which they
originally applied.
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 U.S. 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. 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 J uly 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.
Providing the information requested on this form is voluntary. Failure to provide the information
requested may result in processing delays or the denial of your U.S. passport application.
Public reporting burden for this collection of information is estimated to average 5 minutes per
response, including time required for searching existing data sources, gathering the necessary
data, providing the information and/or documentation required, and reviewing the final collection.
You do not have to supply this information unless the 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, DC 20520.
For more information, please visit our website at travel.state.gov.