United States Department of State - :v$y'

Washington, D. C. 20520

a~c I o ma q

Case No.: 200900535 a .

Segment: PPT ' , .$wZx..4 * > : , ,\ , . *\; #%*3s$..;

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Ms. Pamela Barnett . -3 . '< 2 Y ' & %-:.t:*<

254 1 Warrego Way % 3 . , a< lLe- ...- I * .- ..:.$$ - >

Sacramento, CA 95826 , '. '-2 . 1- > ' V.

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Dear Ms. Barnett: , . .,, ~4

I \ >: 1

I refer to your request letter we received on January 2,2009 under the of Information Act (Title 5 USC Section 552) for a copy of documents relating to Stanley Ann Dunham. We initiated a search of the Office of Passport - I,

E .I Services. . a - , :

3 -.:3 - > a ~ 5

L 334 . . z * ' -63

*.%.<

The search of the records of the Office of Passport Services has been completed and has resulted in the retrieval of six documents that are responsive ,, to your request. These documents have been reviewed and the results are set ,.- forth in the accompanying letter (with enclosures) of Jonathan M. Rolbin, . \ $ I

Director.

We have now completed the processing of your request. If you have anSf ~ '

questions with respect to our handling of your case, you may write to the . . Office of Information Programs and Services, SA-2, Department of State, ' % . . Washington, D.C. 20522-8100. Please be sure to refer to the case number shown above in all correspondence about this case.

We hope that the Department has been of service to you in this matter.

Sincerely,

Office of Information Programs and Services

Enclosures: As stated

United States Department of State

Wmhutgton, D.C. 20520

In reply refer to: CA/PPT/L/LE - Case Control Number: 20090053 5

Pamela Barnett 254 1 Warrego Way Sacramento, CA 95826

Dear Ms. Barnett:

The following is in response to your request to the Department of State dated January 2,2009, requesting the release of material under the provisions of the Freedom of Information Act (5 U.S.C. 5 552).

We have completed a search for records responsive to your request. The search resulted in the retrieval of six documents that are responsive to your request. After careful review of these documents, we have determined that that all six documents may be released in full.

We did not locate a 1965 passport application referenced in an application for amendment of passport that is included in the released documents. Many passport applications and other non-vital records fkom that period were destroyed during the 1980s in accordance with guidance from the General Services Administration.

Passport records typically consist of applications for United States passports and supporting evidence of United States citizenship. Passport records do not include evidence of travel such as entrancelexit stamps, visas, residence permits, etc. since this information is entered into the passport book after issuance.

This completes the processing of your request.

Bureau of Consular Affairs Passport Services

Enclosure: As stated

FORM A'

DEPARTMElv 1 OF STATE I APPLICATION FOR AMENDMENT OF PASSPORT Amend as shown i n section:

INSTRUCTIONS: A l l requests for inc lus ion of persons must be sworn to (or affirmed) be- = Add v isa pages. fore an Agent o f the Department of State or Clerk o f Court. Photographs, which meet the requirements below, and evidence of c i t ~ z e n s h l p must be submitted for a l l persons to be 0 included by th is amendment. I f such persons hove hod, or been inc luded in, a previous passport, it should be submitted ins tec* of other documents, and Section C completed.

IN C A R E O F

( P L E A S E PRINT NAME IN F U L L ) (First name) (Middle name) (Lost name)

fo r 0 , a c i t i zen

o f the Uni ted States, do h&by request that my passport, which i s enclosed, be amended as / I , . i n d ~ c o t e d below.

INCLUDE MY CHILD(REN), AS FOLLOWS: (A l so complete Section H i f chi ld(ren) acquired c ~ t i z e n s h i ~ by n o t u r o l i r o t i ~ n , and hove not had o previous passport.) B I . 1 (Photo requirements for inclusion) 7 1;

INCLUDE MY (WIFE) (HUSBAND), AS FOLLOWS: (A lso complete Sect ion H i f (w i fe) C I ihurbandi ncouired c i t i zensh io b r natural izat ion. and/or Section I i f w i f e was ~ r e v i o u s l r I inarried befor; March 3, 1931.j

'

(WIFE'S) (HUSBAND'S) F U L L L E G A L NAME P L A C E O F B IRTH (City, State)

STAPLE ONE PHOTO HERE

DO NOT MAR FACE .,

. *.

I " Photos must be ONLY of persons ;o be in- w cluded by t h i s amendment. The two photos I.

must be duplicates, approx~mate ly 2% by I 2H inches i n size; be on thin, unglazed ,? w paper w i t h a plain, l igh t background an<' , Ir

have been taken wi th in 2 years o f dot, a submitted. Photos should be front v i ew

but no t ful l - length, and may not be snap shot, Polaroid, acetoteor f i lm base prints. When more than 1 person i s t o be included, a group photo i s require$. F~ipr photos are acceptable. % . + $

D A T E OF MARRIAGE DO NOT STAPLE SECOND PHOTO

D A T E O F B IRTH ATTACH BY P A P E R C L I P

I

E X C L U D E PERSONS, AS FOLLOWS:

I

0 MY WIFE

0 MY HUSBAND

n MY CHILDREN (Give nomds))

WHO IS/ARE . .

[7 T O A P P L Y FOR SEPARATE PASSPORT

ONOTTOACCOMPANY

6

I

(CHILDIREN)*SI (WIFE'S) I H U S B A N D * ~ ) LAST U. S. PASSPORT

I N NAME O F

NUMBER

U IS SUBMITTED HEREWITH

OTHER DISPOSITION (State)

D A T E ISSUED

DSP-19 1

7 - 64 (OVER) I

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01 SUUT~SUO~ 10 '~JI~IS pal!un aq2 '~SU!E~E Sum 8u!reaq JO 'fiolql~ano 01 a31oj 6q 8updma11e JO '3su!e8a uosea11 jo 12e ALE Bu!n!ru -mas 30 uon~ps!m! lua~adruo~ jo Ie!ueur xno2 JO IJ~OJ e iiq pals!auos uaaq 30 :a~e~s u8!a~oj Xue 30 Xa!~euo!wu aql jo slgauaq aql pa

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32~1% .ALI~ .SS~YOOV 133~15 dlHSN011Vl3S llnd NI ~WVN

AdllON IN30133V YO H1V30 40 IN3A3 3U1 NI f ~~UOAI~ 0 ~1v.a 0

31VO AB 031VNIWY31 SVM 3DVlUHVW Hlt1l8 40 33Vld S.ONV8SllH YaW8Od

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35Vlt1HVW SflOlA3Yd 40 31Va SVM 3WVN N301VW t13H

(luawa+ols lo$uawalddns D u! s+a~j qrJoj +as 'a2!m+ u~q+ arotu pa!llolu 41) 1tl0dS~Vd NI a3CJnl3NI 38 01 SI OHM ONV '1161 '1 H3tlVW 3d0338 a3ltftlVW AlSllOlA3tld SVM 33IM 3SOHM lNV3llddV NV A8 a313ldW03 39 01

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(abD4S '&!3) NI 031V301 (4JnO2 f0 WDN) 3HI 380438 03ZIlV8nlVN SVM OHM

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R E F APPLICATION FOR ~ E P A R T

RENEWAL 0 AMENDMENT 0 EXTENSION

:QUESTED

PROPOSED T R A V E L PLANS I F RETURNING T O U. S. COMPLETE T H E FOLLOWING

I INTEND TO RETURN TO TH U ITED -ES PERMANENTLY TO PORT O F DEPARTURE RESIDE WITHIN - MONTHS

I INTEND TO CONTINUE TO RESIDE ABROAD FOR THE FOLLOWING NAME O F SHIP OR AIRLINE PERIOD A N D PURPOSE /At D.FF//VATE - /KA!P./W

U A d / f i ~ d / J ~ S / + t / C / T / z h DATE O F DEPARTURE

I have not (and no other person ~ n c l u d e d or to be included in the passpor t or documentation has), s i n c e acquiring Lhi ted S t a t e s citi- zenship, been naturalized a s a c i t izen of a foreign s t a t e ; taken an oath or m a h an affirmmion or a her formal declaration of a l l eg i ance to a foreign s ta te ; entered or served in the armed forces of a foreign s ta te ; accepted or performed the dut ies of any office, post , o r ern- ployment under the government of a foreign s t a t e or pol i t ica l subdivision thereof; voted in a political e lect ion in a foreign s t a t e or p a r t ic ipated in an e lect ion or p lebisc i te to determine the sovereignty over foreign territory; made a formal renunciation of nationality e i ther in the .United S ta t e s or before a diplomatic or consular officer of t he United S t a t e s in a foreign s ta te ; ever sought or claimed the bene- f i t s of the nationality of any foreign s t a t e ; or been convicted by a court or court martial of competent jurisdiction of committing any a c t of treason against, or attempting by force to overthrow, or bearing arms agains t , the United Sta tes , or conspiring to overthrow, put down or t o des t roy by force, the Government of the United States.

( I f m y o f the above-mentioned acts or condit ions h w e been performed by or apply t o the applicant, or to any other person included in the passport or documentation. the portion which applies should be stmck out, and a sup kmentory explanatory statement under oo*, (or aff irmation) by the person t o whom the porfron i s applicable should be attached and m a J o part o f th is application.)

Subscribed and

I P R E V I O U S M A R R I A G E T E R M I N A T E D B Y I

8 I

L

STATEMENT O F ACTION BY POST UPON DEPARTMENT'S AUTHORIZATION ( T o be executedonly in connection wi th cases r e f e r r u f t o Dept.)

, T H E 0 P A S S P O R T 0 R E N E W E D T O

0 C A R D O F I D E N T I T Y 0 A M E N D E D AS R E Q U E S T E D

0 C E R T I F I C A T E 0 E X T E N D E D T O

W A S

N A M E

S T A P L E O N E P H O T O H E R E DO NOT MAR FACE

T h e passpor t photos required must w be approximately 2% by 2% i nches in s ize; - a w be on thin unglazed paper, show full front > 5: view of appl icant with a p la in , l ight back-- 7 w

ground; and have been taken within 2 years m D. P

of date submitted. When dependents a r e in- m % cluded they should be shown in a-group pho- -

tograph. T h e consul will not accep t photos -

rhat a r e not a good l i keness . Color photo- graphs a re acceptable .

B I R T H P L A C E B I R T H D A T E

-'.. 1 ah.

;*: A U T H O R I T Y (Consul o f the Uni ted States o f America)

X X

i (Photo reqrured for zncfusions)

I

DG not staple second photo. Attach loosely by p@er clip. 1 i I

x

OPINION O F CONSULAR O F F I C E R -

(Consul o f the Uni ted States o f Amer ica) b

FS -299 In cer ta ln c a s e s specif ic authorization by the Department will be required. In rhese c a s e s an extra copy of t he form should 7 - 64 be prepared Upon receipt of the Pepar tment ' s reply the extra copy should be transmitted with a notarion of t h e act ion taken,

D E P A R T M E N T O F S T A T E

REQUEST BY UNiTED STATES NATIONAL FOR AND REPORT OF EXCEPTION T O SECTION 53.1, TITLE 22 OF THE CODE OF FEDERAL REGULATIONS

t

I- R E Q U E S T

i h c r r e been ~nformed that m y passpor t is not valid and that a valid passpor t i s required by law to enter the 1 t t t . 1 request that an exception be granted to me, a s ~ r o v i d e d in Sect ion 1).2(h), T i t l e 22 o f the Code o t Fecleral Regulat ions. I understand that a f e e o t $25 i s required under Section 53.2(h) and I will remit s u c h fee r t l rI,:- Passpor t O f f ~ c e , Department of S ta te , Washington,

i (Sigrrature) f

REPORT - Pursuant to Section 215 of the I m m i g r a t i o h n d Nationality Act of 1952 1 T G . Director, P a s s p o r t Off ice ~.

I i lepartment of S ta te Washington, D. C. 20524 Attn: PT/AC

I SUBJECT

KF i D E S C R ~ P T ~ O N 5 t 6 n STA!LEY -- AIW SOETORO - Brow Brown -7 s - - 135 :

HCME ADDRESS D ia la 1am.n &trzman 22 Pav., D jakartz, Indonesi k c noluilu, 1617 South 3 e r e t ~ n i . a ~ c / o Stanley Dl .I T

a V W ' J w

BIRTHDATE NATURALIZATION DATE PASSPORT NO., U H I E AND PLACE br I. 4HCE NOT. 29, 342 I\T , A .

. F 777788 1

BIQ'HPLACE R-19-65 h!ichita, Kansas ~ono l - Hamii b

A '3 DEPARTURE FROM UNITED STATES

DATE AND PLACE OF DEPARTURE I DESTINATION

I October 196'7, Honolulu, Havhii I Djakarta, Indonesia

FLIGHT NUMBER OR VESSEL

- NAME OF CARRIER

J z p n A i r l i n e s I 1 TRAVEL T O UNITED STATES

DATE AND PLACE OF DEPARTURE FROM ABROAD I IDENTITY DOCUMENTS PRESENTED P i October 20, 1971 , D j a k ~ r t a . , Indonesia 1 Passpor t as shorn ebove

FLIGHT NUMSER OR VESSEL NAME OF CARRIER

Pan American Aiw2ps DESTINATION

I October 21, 1971, Honolulu, H a w a i i Honoful u, Iiawii ACTION TAKEN

Identity and ci t izenship es tab l i shed .

Exception granted under 22 CFR 53.2(h).

I

, . 1

QCT2 ( Inspec to r l j q 7 l s Stamp)

I ~ ( i r n m i g r c t i o n and Na+ural i id+ion Service) 1 SIGNATURE (Immigration Officer'

POST ACTION REGISTRATION APPROVED

Dote June * f lg7 Exp,res

~ x p r r e g ~ ~ ~ f 81 CARD OF IDENTITY AND REG.

No Fee passport 0 $3 fee collected (for card)

0 0t f8c lo l posrport 0 48-page passpwt

TO BE COMPLETED BY AN APPLICANT WHO BECAME A CITIZEN THROUGH NATURALIZATION I IMMIGRATED TO THE U 5. 1 RESIDED CONTINUOUSLY IN T H E U.S. NATURALIZATION CERTIF ICATE NO. 4: ,+ (Month, year) From (Year) T o (Year) 3 Subm~tted he rew~th

- * , - ,

Seen and returned . < ,i r

0 P r e v ~ o v r l y submttted

PLACE NATURALIZED ( C ~ t y , state) NATURALIZATION COURT DATE N A T U R A L I Z E D

I I

COMPLETE ONLY IF OTHERS ARE TO BE INCLUDED IN PASSPORT OR REGISTRATION AND SLP(MIT GROUP PHOTOGRAPH (WIFE'S) (HUSBAND'S) FULL LEGAL NAME ' =NATIVE BORN NATURALIZATION ~ E R T I FICATE NO. ,*

=NATURALIZED 0 Seen and r e t u r n e t l . PLACE NATURALIZED (City, state) NATURALIZATION COURT < DATE N A T U R A L I Z E D

I I (WIF@S) (HUSBAND'S) PLACE OF BIRTH (c l ty , State or Prov~ncs, country) 1 D A T E OF B IRTH (Ma.. Qay, Year) t

\

- -- -

FORM 9-74 FS-176 (OVER - YOU MUST COMPLETE PAGE 2) 1 FORM APPROVED BUDGET BUREAU NO. 47-ROO12

- - -- I 2: -

NAME IN F U L L OF CHILDREN INCLUDED PLACE OF BIRTH (City, stote/povlnce. country) (Month, OATE OF day, year) RESIDED I N U.S. (From-To)

(leas)

s!ql aw alojaq (palul!gje) 01 UJOMS pue paq!~~qng

'PPSI 3Sn 81 lapun ;uawuos!lds! lo/pue au!j dq alqeqs!und s(suo!~ -elnla podssed ag 40 lo u!alaq pau!quo3 suo!l3!qsal all1 40 uo!lelo!n u! llodssed e 40 asn aql '&PSI 3Sn 81 40 suo!s!no~d aql Japun iualuuos!ldw! lo/pue au!] Iq alqe -qs!und s! uo!le3!1dde s!q ol luenslnd panss! llodssed e jo uo!lel!gnw JO uo!lela;lW .ZPSI 3sn 81 lo/pue 1001 3sn 81 40 suo!s!~old aq lapun luawuos!dlu! 101 pue aug

---.ha.a~oeuslund ae ullmelalll oalllwons sluawnson By!lJoddns laqlo lo sl!nep!j4e u! lo suo!;e3!ldde llodssed u! Allngll!~ pue Lllu!~ouy apew sluawalels asp3 BNINUVM r

- - @itor ~7~~12,6, $/ ' #>arw (a+~al NO a31wvw isvi SV* I@

3dlM 80 ONVBSnH 30 3WVN 1V331 llfld lN3S3bd a3l8UVW 83A3N SVM I f)

/# 'n7fl @mH 1V 3NlalS28

.s-n NI a3a1s3tr HIOW OW ~181s 30 3~va s.83~10~

- - - - - - - - - - . - - -

F P 1- E. 0243

POST LOCATION Z3-1Carta, i n d o n s a i a KLICATION F O ~ IB PASSPORT REGISTRAT~OQ~

te ALL entries in all sections that apply to you. If informat ion is unknown, PASSPORT ISS UED REGISTRATION APPROVED

Inknown.'' DO not I m biar* prr Use additional sheets .here spaa No. Z 3 3 3 7 2 2 1 Date provided b n o t adequate. PRINT OR TYPE ENTRIES. Date 4//23/31 Expires

TO BE COMPLETED BY ALL APPLICANTS '

Explres 4/2 7/86 CARD OF IDENTITY AND REG.

(First name) (Middle name) ( L e n name) a $3 Application fee No. collected

STANLEY ANN DUNHAM a $10 Fee collected Oat' 17 N o Fee passport $6 fee collected ( f o r card)

1. a citizen o f the U n ~ t e d States, d o hereby apply f o r ( a passport) (reglmatlon).

Official passport 48-page 96-page passport -

SEX (MF) BIRTHPLACE (City, State o r Province, Country) B I R T H D A T E APPLICANT'S EVIDENCE OF CITIZENSHIP

F p. l !c~rT-A, M o n t h Day Year

B ~ r t h Certificate m s s p o r t KANSAS, U.S.A. Nov . 1 29 1 1942 ~ e r t i f i c a t e of Natura l izat~on o r C~tizenship

HEIGHT -COLOR OF H A I R COLOR O F EYES S O C I A L SECURITY NO. Data: 6 1-476 (Spell out) (Spell out) ( N o t mandatory)

Bearer's Name. Submitted H e r e w ~ t h

5 FL 2 in. BROWN BROWN 535-40-8522 d a n c e l e d 81 Returned -- Place: 7- Seen & Returned

NOW RESIDING A T J a l a n Daksa 1/14, Kebayoran Baru MY LAST REGISTRATION AS A CITIZEN

J a k a r t a Sel a tan. Indones ia O F T H E U N I T E D STATES WAS APPROVED

PERMANENT RESIDENCE (Street Addrasq City, State, U.S. ZIP Code) (If mme as above, Location o f Registering Of f ice Date o f Registration so indicate) 1617 South Bere tan ia , Apt.1008, Hon., Hawai i

. . 1 1 949-2317

1E ANSWER 1S"YES." E X P L A I N WHEN +ND WHY

B (PHOTO REQUIREMENTS F O PERSONS T O BE INCLUDED)

I Photos must be O N L Y o f persons I to be included (other than passport bearer). When more than one person is t o be included, a group phot* graph o f the inclusions is required.

CONSULATE W I L L STAPLE PHOTO O F INCLUSIONS HERE.

DO N O T IMPRESS S E A L O N PHOTOGRAPHS.

I I have n o t (and n o other person included i n th is application has), since acquiring Uni ted States citizenship, performed any o f the acts listed i n Section 1 o n the reverse o f this application f o r m (unless explanatory statement is attached). I solemnly swear (or af f i rm) that the statements made on all of the pages o f this appl!cation are t rue and the photograph(s) attached is (are) a likeness o f me and bf those persons t o be

I I I (SEAL) - /,L /L 17 4; ki.. 3%-Li. ii, 1, r.,

( T o be signed a t same t ime b y husbandwi fe to be included i n passport) ( T o be signed b; Applicant i n presence of person administering a h ) I

Submitted Herewith Canceled & Returned Seen & Returned

CHILD(REN)'S EVIDENCE

Submit ted Herewith Canceled & Returned Seen & Returned

BIRTHPLACE (Citv,.StamcrPr~Ina~, Carnay) BIRTH DATE (Mo,Day,Yr.)

Vt,

CHILD(REN)'S NAME(S) I N F U L L

Subscribed and sworn t o (affirrnea) before me thls A? day o f

33 Consul o f the Unl ted States a t 33LG & dGiL$!!

I / &gnature o f &r& takin<&plication)

OPTIONAL FORM 178 (OVER - YOU MUST COMPLETE PAGE 2) January 1978 (FORMERLY FS-176) D e p t o f State

BIRTHPLACE(S) (City, State o r Country)

BIRTH DATE(S) (Mo., Day, Yr.)

AlNO SWtlV 3UHM NI MU04 40 X3W8 NO

OF-178 1-78 PAGE 2

C 1 TO BE COMPLETED BY AN APPLICANT WHO BECAME A CITIZEN THROUGH NATURALIZATION 1 '

*

' D

- - - - - -

.I IMMIGRATED T O THE I RESIDED CONTINUOUSLYIN THE NATURALIZATION CERTIFICATE NO.

I I

TO BE COMPLETED BY ALL APPLICANTS OCCUPATION [VISIBLE DISTINGUISHING MARKS

E

O N (Date o f b i r th)

I q Husband

Chi ld

Submined herewith q Seen and returned q Previously submitted

N A T U R A L I Z A T I O N COURT D A T E N A T U R A L I Z E D

U.S. (Month, year)

PROGRAM OFFICER, FORD FOUNDATION

*

U.S. F r o m (Year) T o (Year)

none

OFORMER HUSBAND WAS U.S. CITIZEN

n FORMER HUSBAND WAS NOT U.S. CITIZEN

PLACE N A T U R A L I Z E D (City, state)

-EN MUST W P L E T E FOLLOYVlNG IF CHILDREN OF A PREVIOUS MARRIAGE ARE MlCLUOED OR IF PRWIUSLY MARRIED BEFORE MARCH 3,1931 I WAS PREVIOUSLY MARRIEDON I T 0 (Ful l legal name) WHO WAS BORN A T (City, State, Country)

PREVIOUS MARRIAGE TERMINATED BY ODEATH ODIVORCE O N (Date)

L - I

-E IF APPLICANT OR ANY E m UCLlJDa SECTION B WAS NOT BORN IN THE UNITED STATES AN) C W CrrUENSHP PARBTT(S)

I

'ENTERED THE U.S. (Month) (Year)

Applicant

Wife

Before (Name o f Court)

RESIDENCE/CONTINUOUS PHYSICAL PRESENCE I N U.S. From(Year) T o (Year)

Applicant

I Two years c o n t r a c t w i t h Ford Foundat ion f rom January 1981 - December 1982.

Place (City, State)

G

! I I N T E N D T O RETURN T O THE U N I T E D STATES PERMANENTLY D A T E O F DEPARTURE T$ RESIDE WITHIN

a YEARS MONTHS

I I F MOTHER N A T U R A L I Z E D :

Date Certificate No.

0 - . - . . . . - . . - . . . . . - 4

I ! PRIVACY ACT STATEMENT

TR information solicited o n this f is authorized by, b u t n o t l imi ted to, those statutes codif ied i n Tit les 8, 18, and 22, UnitedStatesCode, n d al l predecessor statutes whether o r n o dified, and all regulations issued pursuant t o Executive Order 11295 o f August 5, 1966. T h e pr imary purpoaa fo r soliciting the information is t o establish citizenship, identi ty and enti t lement t o issuance o f a Uni ted Stater Parrport or related facility, and t o properly administer and enforce tha laws pertaining thereto.

T h e in format ion is made available B a rout ine use on a needto-know basis t o personnel o f the Department o f Stata and other g o v w m e n t agencies having statutory o r other lawful author i ty t o maintain such information i n the performance of their off icial duties; pursuant t o a rubpoene o r cour t order; and, ar set f o r t h i n Part 6a, T i t l e 22, Code o f Federal Regulations (See Federal Register Volume 40, pages 45755, 45756,47419 and 47420).

Failure t o provide the information requested on this f o r m may result i n the denial o f a Uni ted States P a p o r t , related document or rewice to the individual seeking such passport, document o r service.

IF KNOWN, FATHER'S RESIDENCE/ PHYSICAL PRESENCE I N U.S. F r o m (Year) T o (Year)

I F F A T H E R N A T U R A L I Z E D :

IF KNOWJ, MOTHEWS RESIDENCE/ PHYSICAL PRESENCE I N U.S. F r o m (Year) T o (Year)

3, Wife

Husband ( Chi ld d

NOTE: The disclosure o f your Social Security Number o r o f the ident i ty and location o f a person t o be not i f ied in t h e event o f death or r c i d e n t is entirely voluntary. However, failure t o provide th is information may prevent the Department of State f r o m providing you w i t h t imely assistance o r . protection i n the event you should encounter an emergency situat:-? whi le outr ide the Uni ted States. I :

Date

I I! ACTS OR CONDITIONS

Certificate No.

\ PROPOSED TRAVEL PLANS (Not Mandatorv)

I I N T E N D T O CONTINUE T O RESIDE A B R O A D FOR T H E FOLLOWING PERIOD A N D PURPOSE

Before (Name of Court)

( I f m y of the belowment ioned acts o r condit ions have b w n performed b y or apply t o the applicant, o r t o any other person t o be i n c l u d d in the passport, the por t ion which applies should be struck out, and a supplementary explanatory statement under oath (o r aff irmation) b y the p n w n to whom t h e por t ion is applicable should be attached and made a par t o f this application.)

I have n o t (and no other person included i n this application has), since acquiring Uni ted States citizenship, been naturalized as a cit izen of a form mt.; taken an oath o r made an aff irmation o r other formal declaration o f allegiance t o a foreign state; entered or served in the s m e d f o r c r of e foreign rar; accepted o r performed the duties o f any office, post, o r employment under the government o f a foreign state o r pol i t ical subdivision themof; m.d. a formal renunciation o f nationali ty either in the Uni ted States or before a diplomatic o r consular off icer o f the Uni ted States in a foreign state; ever sought o r claimed the benefits o f the nationali ty o f any foreign state; o r been convicted by a court o r cour t mart ial o f competent jurisdiction o f commit t ing any act o f treason against, or attempting b y force t o overthrow, o r bearing arms against, the Uni ted States, o r conspiring t o overthrow, put d o w n o r t o destroy b y force, the Government o f the Uni ted States.

WARNING: False statements made knowingly and wi l l fu l ly i n passport applications o r i n affidavito o r other supporting documents l u b m i M thwwith are punishable by f i ne and/or imprisonment under the provisions o f 18 USC 1001 andfor 1 8 USC 1542. Alteration o r mut i la t ion o f 8 pr00t-t bud pursuant t o this application is punishable b y f ine and/or imprisonment under the provisions o f 18 USC 1543. T h e use o f e p-ort i n v i o l m i o n o f the restrictions contained therein o r of the passport regulations is punishable b y f i ne and/or imprisonment undor 18 USC 1644. A l l rtoasmenta and documents submitted are subject t o veri f icaticn.

Place (Ciw, State)

I Drivefs License place of Issue:

J

I Driver's License Place o f Issue:

I q Qther (Specify): Issued i n Name of: I Other . " (Specify): Issued i n Nerne of: I

(FOR USE OF OFFICE TAKING APPLICATION)

'APPLICANT'S IDENTIFYING D O C U M E N T E )

- q Certificate of Natural- ization or Citizenship -,

- U Passport Issue Date:

I D E N T I F Y I N G DOCUMENT(S) OF WIFE/HUSBAND T O BE I N C L U D E D I N PASSPORT

q Certificate o f Natural- ization o r Citizenship No.:

q Passport Issue Date: