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Submitting an Identification Record Request to the FBI

Step 1: Complete the Applicant Information Form.

If the request is for a couple, family, etc., all persons must sign the form.

Include your complete mailing address. Please provide your telephone number and/or e-mail

address, if available.

Step 2: Obtain a set of your fingerprints.

Provide the original fingerprint card. Previously processed cards or copies will not be accepted.

Your name and date of birth must be provided on the fingerprint card. Fingerprints should be

placed on a standard fingerprint form (FD-258) commonly used for applicant or law

enforcement purposes.

Include rolled impressions of all 10 fingerprints and impressions of all 10 fingerprints taken

simultaneously (these are sometimes referred to as plain or flat impressions).

If possible, have your fingerprints taken by a fingerprinting technician. This service may be

available at a law enforcement agency.

To ensure the most legible prints possible, refer to the Recording Legible Fingerprints

brochure.

Step 3: Submit payment.

Option 1: Obtain a money order or cashier’s check for $18 U.S. dollars made payable to the

Treasury of the United States. Please be sure to sign where required.

Option 2: Pay by credit card using the Credit Card Payment Form. Don’t forget to include the

expiration date of the credit card that you are using.

Important note: Cash, personal checks, or business checks WILL NOT be accepted.

Payment must be for the exact amount.

If the request is for a couple, family, etc., include $18 for each person.

If the request is for multiple copies per person, include $18 for each copy requested.

Step 4: Review the FBI Identification Record Request Checklist to ensure that you have included

everything needed to process your request.

Step 5: Mail the required items listed above—signed applicant information form, fingerprint card, and

payment of $18 U.S. dollars for each person or copy requested—to the following address:

FBI CJIS Division – Record Request

1000 Custer Hollow Road

Clarksburg, WV 26306

Note: Although the FBI employs the most efficient methods for processing these requests,

processing times may take approximately five to six weeks depending on the volume of requests

received.

Forms and Links

Identification Record Request Home

New FD-258 Fingerprint Card

FBI Option

- Address Change Request Form

- Applicant Information Form

- Background Check for Employment/Licensing

- Challenge of a Criminal History Record

- Credit Card Payment Form

- Frequently Asked Questions

- Record Request Checklist

- State Identification Bureau Listing

- U.S. Department of Justice Order 556-73

Channeler Option

- Background Check for Employment/Licensing

- Challenge of a Criminal History Record

- FBI-Approved Channelers | List

- Frequently Asked Questions

- State Identification Bureau Listing

- U.S. Department of Justice Order 556-73

Home • About Us • CJIS • Identification Record Request/Criminal Background Check • Submitting an Identification Record Request to the FBI

1-783 (Rev. 6-8-2012)

OMB-1110-0052

APPLICANT INFORMATION FORM

PRIVACY ACT STATEMENT The FBI’s acquisition, retention, and sharing of information submitted on this form is generally authorized under 28 USC 534 and 28 CFR 16.30-16.34. The purpose for requesting this information from you is to provide the FBI with a minimum of identifying data to permit an accurate and timely search of criminal history identification records. Providing this information (including your Social Security Account Number) is voluntary; however, failure to provide the information may affect the completion of your request. The information reported on this form may be disclosed pursuant to your consent, and may also be disclosed by the FBI without your consent pursuant to the Privacy Act of 1974 and all applicable routine uses. Under the Paperwork Reduction Act, you are not required to complete this form unless it contains a valid OMB control number. The form takes approximately 3 minutes to complete. Applicant Information* Denotes Required Fields *Last Name *First Name Middle Name 1 Middle Name 2 *Date of Birth Last Four Digits of Social Security Number Applicant Home Address *Address *City *State *Postal (Zip) Code *Country Phone Number E-Mail U.S. Citizen or Legal Permanent Resident Yes No Country of Citizenship Country of Residence Mail Results to Address C/O ATTN Address City State Postal (Zip) Code Country Phone Number (if different from above) Payment Enclosed (please check appropriate box) CASHIER’S CHECK MONEY ORDER CREDIT CARD FORM Number of Copies X $18 per Copy = Total Payment of $ Enclosed Reason for Request: Personal review Challenge information on your record Adoption of a child in the U.S. International adoption Live, work, or travel in a foreign country Other * APPLICANT SIGNATURE DATE Mail the signed applicant information form, fingerprint card, and payment of $18 U.S. dollars for each person or copy requested - to the following address: FBI CJIS Division – Record Request 1000 Custer Hollow Road Clarksburg, West Virginia 26306 You may request a copy of your own identification record to review it or obtain a change, correction, or an update to the record.

1-785 (1-31-10)

Did You Remember To......?

Please review and check the boxes below to ensure that you have included everything needed to process your

request.

Include a completed application form.

Sign your application. Note: If the request is for a couple, family, etc., all must sign the application.

Include a completed fingerprint card. A completed fingerprint card includes the following:

1. Name

2. Date of Birth

3. Descriptive Data

4. All 10 rolled fingerprint impressions.

5. The plain impressions, including thumbs of both hands.

6. Current fingerprint card—no older than 18 months.

Include a cashier’s check*, money order, or credit card payment for $18.00 per request.

Note: This amount must be exact.

If paying by cashier’s check or money order, make it payable to the Treasury of the United States.

If using a credit card, please ensure our credit card form is filled out completely.

You must include the expiration date of the credit card that you are using.

NOTE: Cash or Personal/Business Checks are Not an Accepted Form of Payment.

Include your contact information (for example, e-mail address, and telephone number)

in case we need to contact you.

* A cashier’s check is drawn by a bank on its own funds and signed by the bank’s cashier.

1-786 (1-31-10)

Credit Card Payment Form* Denotes Required Fields

Applicant Name

* Name (as it appears on credit card)Company Name (if applicable)* Billing AddressBilling Address 2* City* State/Province* Postal (ZIP) Code* Country

* Credit Card #: * Expiration Date (MM/YYYY) * Total Amount To Be Billed To Credit Card $( x $18 US Dollars Per Request)

* Card Holder Signature

No Charge Backs or RefundsAll Sales Final

N.C.STATEBUREAUOFINVESTIGATION

RighttoReviewProcess

InstructionsforReviewingYourNorthCarolinaCriminalHistoryRecord

for Adoption Purposes

— Domestic or International —

SBI – Criminal Information and Identification Section

5/2/2012

This informational packet includes all the necessary documentation and requirements needed to obtain a copy of your North Carolina criminal history record. Packet also includes instruction for the local law enforcement agency to assist in this process.

Page 2 RIGHT TO REVIEW PROCESS N.C. State Bureau of Investigation

The Right to Review Process offered by the N.C. State Bureau of Investigation affords an individual

the opportunity to receive a copy of their North Carolina criminal history record. This record check

consists of a search for previous arrest(s) and associated disposition(s), if available, for which the

SBI received a fingerprint card from the arresting agency. This process does not include any

criminal history information that may be maintained at the national level or by another state.

There is a $14.00 fee charged for each Right to Review requested. This process consists of a

biometric-based (fingerprint-based) search of the SBI’s computerized criminal history file.

Therefore, a complete set of legible fingerprints, including all ten fingers, is required to complete the

Right to Review request. Exceptions are made for situations such as finger amputations and other

deformities. If the fingerprints are of insufficient quality to conduct the search or if the fingerprint

card is not completely and accurately filled out, the fingerprint card will be returned to the requestor

and another set of fingerprints will be required to complete the process.

The result of the search will include a formal response letter on SBI letterhead indicating the findings

of the Right to Review Process. If there is a criminal history record matching the fingerprints on the

provided fingerprint card, a copy of that record will be provided as an attachment to the response

letter.

The following documents are included in this packet in order to provide the necessary guidance and

instruction for completing this process:

1. Right to Review Request Form

2. Legal Authorization for Right to Review

3. Instructions — Fingerprinting for Right to Review

Requests can only be accepted by the SBI through the mail and the results of the search can only be

mailed back to the requestor via first-class mail. The SBI does not utilize shipping alternatives

such as FedEx or UPS. Upon receipt of the results, the requestor may freely share this information

with whoever they would like; however, the SBI is not legally authorized to provide the results of

the search to a third party.

RIGHT TO REVIEW PROCESS

N.C. State Bureau of Investigation RIGHT TO REVIEW PROCESS Page 3

Right to Review Request Form

COMPLETE FILLABLE FORM BELOW -OR- PRINT COPY & CLEARLY TYPE or PRINT

Applicant’s Full Name: Date:

Applicant’s Mailing Address:

City: State: Zip: Phone Number:

Date of Birth: Sex: (Check X one)

Male

Race: Female

Reason for Request:

The following items are required for completion of your request: 1) Completed Right to Review Request Form. Please make a copy for personal records and submit original

to the N.C. State Bureau of Investigation as indicated below. A complete set of fingerprints on a FD-258 applicant Fingerprint card. You can have a set of your fingerprints made at your local law enforcement agency (police department or sheriff’s office). Further instructions for the law enforcement officer taking your fingerprints are provided on page 5. DO NOT FOLD FINGERPRINT CARD.

2) There is a $14.00 fee for each Right to Review request. The fee must be in the form of a certified check OR money order made payable to N.C. State Bureau of Investigation. NO PERSONAL CHECKS WILL BE ACCEPTED. Multiple requests may be submitted in one envelope. Please do not endorse certified check or money order on back as it will be returned to you.

3) Mail the above items to: North Carolina State Bureau of Investigation Criminal Information and Identification Section Attention: Applicant Unit — Right to Review 3320 Garner Road - Post Office Box 29500 Raleigh, North Carolina 27626-0500

If any of the required items listed above are missing or incomplete, the request will be returned to you.

Requests will only be accepted by mail and we will only return the response to the applicant by first class mail. We do not utilize companies such as Federal Express-Overnight for returns. Please do not send a prepaid envelope as it will be returned to you with your request. WE CANNOT SEND RESULTS TO A THIRD PARTY.

* For further questions, please call the SBI at (919) 662-4509, extension 6266. *

Page 4 RIGHT TO REVIEW PROCESS N.C. State Bureau of Investigation

N.C. Administrative Code Title 12 Chapter 4 Subchapter F .0404 INDIVIDUAL’S RIGHT TO REVIEW HIS OR HER OWN CRIMINAL HISTORY RECORD (a) An individual may obtain a copy of his or her own criminal history record by submitting a written

request to the North Carolina State Bureau of Investigation, Criminal Information and Identification Section, Attention: Applicant Unit - Right To Review, 3320 Garner Road, Post Office Box 29500, Raleigh, North Carolina 27626-0500. The written request must be accompanied by a certified check or money order in the amount of $14.00 payable to the North Carolina State Bureau of Investigation, and must contain proof of identity* to include:

1. Complete name and address 2. Race 3. Sex 4. Date of birth 5. Social security number — Optional ** 6. Set of rolled-inked fingerprint impressions

This procedure guarantees positive identification and insures that the individual receives a copy of his or her own record as currently maintained in the SBI Computerized Criminal History files.

* Proof of identity will be required when you get fingerprinted at your local law enforcement agency.

** Disclosure of social security number is entirely voluntary and not required. If disclosed, the social security number will be utilized to assist with accurate identification/exclusion of possible criminal history records.

(b) The accuracy and completeness of an individual’s record may be challenged by submitting the

“Written Exceptions” form available from the SBI. (c) Upon receipt of the Written Exceptions form, the Criminal Information and Identification Section

shall initiate an internal record audit of the challenger’s record to determine its accuracy. If any inaccuracies or omissions are discovered, the Criminal Information and Identification Section will make the appropriate additions, deletions or alterations to the record. Notice of any changes made will be given to the challenger, and to any agency to which the inaccurate or incomplete information has been disseminated. The challenger shall be informed in writing of the results of the audit.

(d) If the audit fails to disclose any inaccuracies, or if the challenger wishes to contest the results of

the audit, he or she is entitled to an administrative hearing pursuant to G.S. 150B-23. History Note: Statutory Authority G.S. 114-10; 114-10.1; 114-19.1 Eff. November 1, 1991.

LEGAL AUTHORIZATION FOR RIGHT TO REVIEW

N.C. State Bureau of Investigation RIGHT TO REVIEW PROCESS Page 5

Instructions for Law Enforcement Officer Taking Fingerprints The bearer of this letter is seeking to obtain a copy of his or her criminal history record information

through the Right to Review Process. Authorization for this process can be found in 12 NCAC 4F

.0404 of the N.C. Administrative Code. In order to complete the Right to Review process, the

requestor must be fingerprinted by a law enforcement official and then provide those fingerprints to

the North Carolina State Bureau of Investigation. The following are the necessary steps to be

followed by the law enforcement officer:

Step 1 — Identity Verification

Verify the identity of the bearer of this letter by requesting a driver’s license or another

government-issued picture identification card. Ensure the identifying data on the ID

card corresponds to the identifying data provided by the requestor.

Step 2 — Completing Fingerprint Process

The fingerprints must be collected using a FD-258 applicant fingerprint card.

The following is required information to be included on the fingerprint card:

1. Name of person requesting the Right to Review Include all married and maiden names if the requestor is a female

2. Race, Sex, and Date of Birth 3. Date, address, and signature of requestor 4. Reason Fingerprinted: Right to Review 5. Date and signature of the official taking the fingerprints. The law officer’s signature

is an indication that he/she has verified the proof of identity of the bearer of this letter. Social Security Number – Optional *

* Disclosure of social security number is entirely voluntary and not required. If disclosed, the social security number will be utilized to assist with accurate identification/exclusion of possible criminal history records.

Step 3 — Provide Copy of Fingerprint Card

Upon completion of the fingerprinting process, provide individual with the completed

fingerprint card. The requestor must forward the fingerprints and other required

documentation to the North Carolina State Bureau of Investigation.

Thank you for your assistance in this matter. For further questions or clarification, contact the SBI at (919) 662-4509, extension 6266.

FINGERPRINTING FOR THE PURPOSES OF A RIGHT TO REVIEW

Form SS-5 (08-2011) ef (08-2011) Destroy Prior Editions

Application for a Social Security Card

Page 1

SOCIAL SECURITY ADMINISTRATION

Applying for a Social Security Card is free!

USE THIS APPLICATION TO:● Apply for an original Social Security card ● Apply for a replacement Social Security card ● Change or correct information on your Social Security number record

IMPORTANT: You MUST provide a properly completed application and the required evidence before we can process your application. We can only accept original documents or documents certified by the custodian of the original record. Notarized copies or photocopies which have not been certified by the custodian of the record are not acceptable. We will return any documents submitted with your application. For assistance call us at 1-800-772-1213 or visit our website at www.socialsecurity.gov.

Original Social Security CardTo apply for an original card, you must provide at least two documents to prove age, identity, and U.S. citizenship or current lawful, work-authorized immigration status. If you are not a U.S. citizen and do not have DHS work authorization, you must prove that you have a valid non-work reason for requesting a card. See page 2 for an explanation of acceptable documents.

NOTE: If you are age 12 or older and have never received a Social Security number, you must apply in person.

Replacement Social Security CardTo apply for a replacement card, you must provide one document to prove your identity. If you were born outside the U.S., you must also provide documents to prove your U.S. citizenship or current, lawful, work-authorized status. See page 2 for an explanation of acceptable documents.

Changing Information on Your Social Security RecordTo change the information on your Social Security number record (i.e., a name or citizenship change, or corrected date of birth) you must provide documents to prove your identity, support the requested change, and establish the reason for the change. For example, you may provide a birth certificate to show your correct date of birth. A document supporting a name change must be recent and identify you by both your old and new names. If the name change event occurred over two years ago or if the name change document does not have enough information to prove your identity, you must also provide documents to prove your identity in your prior name and/or in some cases your new legal name. If you were born outside the U.S. you must provide a document to prove your U.S. citizenship or current lawful, work-authorized status. See page 2 for an explanation of acceptable documents.

LIMITS ON REPLACEMENT SOCIAL SECURITY CARDSPublic Law 108-458 limits the number of replacement Social Security cards you may receive to 3 per calendar year and 10 in a lifetime. Cards issued to reflect changes to your legal name or changes to a work authorization legend do not count toward these limits. We may also grant exceptions to these limits if you provide evidence from an official source to establish that a Social Security card is required.

IF YOU HAVE ANY QUESTIONSIf you have any questions about this form or about the evidence documents you must provide, please visit our website at www.socialsecurity.gov for additional information as well as locations of our offices and Social Security Card Centers. You may also call Social Security at 1-800-772-1213. You can also find your nearest office or Card Center in your local phone book.

Form SS-5 (08-2011) ef (08-2011) Page 2

EVIDENCE DOCUMENTSThe following lists are examples of the types of documents you must provide with your application and are not all inclusive. Call us at 1-800-772-1213 if you cannot provide these documents.

IMPORTANT : If you are completing this application on behalf of someone else, you must provide evidence that shows your authority to sign the application as well as documents to prove your identity and the identity of the person for whom you are filing the application. We can only accept original documents or documents certified by the custodian of the original record. Notarized copies or photocopies which have not been certified by the custodian of the record are not acceptable.

Evidence of AgeIn general, you must provide your birth certificate. In some situations, we may accept another document that shows your age. Some of the other documents we may accept are:● U.S. hospital record of your birth (created at the time of birth)● Religious record established before age five showing your age or date of birth● Passport● Final Adoption Decree (the adoption decree must show that the birth information was taken from the original

birth certificate)Evidence of IdentityYou must provide current, unexpired evidence of identity in your legal name. Your legal name will be shown on the Social Security card. Generally, we prefer to see documents issued in the U.S. Documents you submit to establish identity must show your legal name AND provide biographical information (your date of birth, age, or parents' names) and/or physical information (photograph, or physical description - height, eye and hair color, etc.). If you send a photo identity document but do not appear in person, the document must show your biographical information (e.g., your date of birth, age, or parents' names). Generally, documents without an expiration date should have been issued within the past two years for adults and within the past four years for children.As proof of your identity, you must provide a:● U.S. driver's license; or● U.S. State-issued non-driver identity card; or● U.S. passportIf you do not have one of the documents above or cannot get a replacement within 10 work days, we may accept other documents that show your legal name and biographical information, such as a U.S. military identity card, Certificate of Naturalization, employee identity card, certified copy of medical record (clinic, doctor or hospital), health insurance card, Medicaid card, or school identity card/record. For young children, we may accept medical records (clinic, doctor, or hospital) maintained by the medical provider. We may also accept a final adoption decree, or a school identity card, or other school record maintained by the school.

If you are not a U.S. citizen, we must see your current U.S. immigration document(s) and your foreign passport with biographical information or photograph.

WE CANNOT ACCEPT A BIRTH CERTIFICATE, HOSPITAL SOUVENIR BIRTH CERTIFICATE, SOCIAL SECURITY CARD STUB OR A SOCIAL SECURITY RECORD as evidence of identity.

Evidence of U.S. CitizenshipIn general, you must provide your U.S. birth certificate or U.S. Passport. Other documents you may provide are a Consular Report of Birth, Certificate of Citizenship, or Certificate of Naturalization.

Evidence of Immigration StatusYou must provide a current unexpired document issued to you by the Department of Homeland Security (DHS) showing your immigration status, such as Form I-551, I-94, or I-766. If you are an international student or exchange visitor, you may need to provide additional documents, such as Form I-20, DS-2019, or a letter authorizing employment from your school and employer (F-1) or sponsor (J-1). We CANNOT accept a receipt showing you applied for the document. If you are not authorized to work in the U.S., we can issue you a Social Security card only if you need the number for a valid non-work reason. Your card will be marked to show you cannot work and if you do work, we will notify DHS. See page 3, item 5 for more information.

Form SS-5 (08-2011) ef (08-2011) Page 3

HOW TO COMPLETE THIS APPLICATION

Complete and sign this application LEGIBLY using ONLY black or blue ink on the attached or downloaded form using only 8 ½” x 11” (or A4 8.25” x 11.7”) paper.

GENERAL: Items on the form are self-explanatory or are discussed below. The numbers match the numbered items on the form. If you are completing this form for someone else, please complete the items as they apply to that person.

4. Show the month, day, and full (4 digit) year of birth; for example, “1998” for year of birth.

5. If you check “Legal Alien Not Allowed to Work” or “Other,” you must provide a document from a U.S. Federal, State, or local government agency that explains why you need a Social Security number and that you meet all the requirements for the government benefit. NOTE: Most agencies do not require that you have a Social Security number. Contact us to see if your reason qualifies for a Social Security number.

6., 7. Providing race and ethnicity information is voluntary and is requested for informational and statistical purposes only. Your choice whether to answer or not does not affect decisions we make on your application. If you do provide this information, we will treat it very carefully.

9.B., 10.B. If you are applying for an original Social Security card for a child under age 18, you MUST show the parents' Social Security numbers unless the parent was never assigned a Social Security number. If the number is not known and you cannot obtain it, check the “unknown” box.

13. If the date of birth you show in item 4 is different from the date of birth currently shown on your Social Security record, show the date of birth currently shown on your record in item 13 and provide evidence to support the date of birth shown in item 4.

16. Show an address where you can receive your card 7 to 14 days from now.

17. WHO CAN SIGN THE APPLICATION? If you are age 18 or older and are physically and mentally capable of reading and completing the application, you must sign in item 17. If you are under age 18, you may either sign yourself, or a parent or legal guardian may sign for you. If you are over age 18 and cannot sign on your own behalf, a legal guardian, parent, or close relative may generally sign for you. If you cannot sign your name, you should sign with an "X” mark and have two people sign as witnesses in the space beside the mark. Please do not alter your signature by including additional information on the signature line as this may invalidate your application. Call us if you have questions about who may sign your application.

HOW TO SUBMIT THIS APPLICATIONIn most cases, you can take or mail this signed application with your documents to any Social Security office. Any documents you mail to us will be returned to you. Go to https://secure.ssa.gov/apps6z/FOLO/fo001.jsp to find the Social Security office or Social Security Card Center that serves your area.

Form SS-5 (08-2011) ef (08-2011) Page 4

PROTECT YOUR SOCIAL SECURITY NUMBER AND CARDProtect your SSN card and number from loss and identity theft. DO NOT carry your SSN card with you. Keep it in a secure location and only take it with you when you must show the card; e.g., to obtain a new job, open a new bank account, or to obtain benefits from certain U.S. agencies. Use caution in giving out your Social Security number to others, particularly during phone, mail, email and Internet requests you did not initiate.

PRIVACY ACT STATEMENTCollection and Use of Personal Information

Sections 205(c) and 702 of the Social Security Act, as amended, authorize us to collect this information. The information you provide will be used to assign you a Social Security number and issue a Social Security card.

The information you furnish on this form is voluntary. However, failure to provide the requested information may prevent us from issuing you a Social Security number and card.

We rarely use the information you supply for any purpose other than for issuing a Social Security number and card. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following:

1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;

2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department of Veterans' Affairs);

3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and

4. To facilitate statistical research, audit or investigative activities necessary to assure the integrity of Social Security programs.

We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.Complete lists of routine uses for this information are available in System of Records Notice 60-0058 (Master Files of Social Security Number (SSN) Holders and SSN Applications). The Notice, additional information regarding this form, and information regarding our systems and programs, are available on-line at www.socialsecurity.gov or at any local Social Security office.

This information collection meets the requirements of 44 U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995 . You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 8.5 to 9.5 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form SS-5 (08-2011) ef (08-2011) Page 5

Form Approved OMB No. 0960-0066

SOCIAL SECURITY ADMINISTRATION Application for a Social Security Card

1

NAME TO BE SHOWN ON CARD

First Full Middle Name Last

FULL NAME AT BIRTH IF OTHER THAN ABOVE

First Full Middle Name Last

OTHER NAMES USED

2 Social Security number previously assigned to the person listed in item 1

3PLACE OF BIRTH(Do Not Abbreviate) City State or Foreign Country

Office Use Only

FCI

4DATE OF BIRTH MM/DD/YYYY

5 CITIZENSHIP( Check One )

U.S. CitizenLegal Alien Allowed To Work

Legal Alien Not Allowed To Work(See Instructions On Page 3)

Other (See Instructions On Page 3)

6ETHNICITYAre You Hispanic or Latino? (Your Response is Voluntary)

Yes No

7RACE

Select One or More (Your Response is Voluntary)

Native Hawaiian

Alaska Native

Asian

American Indian

Black/African American

Other Pacific Islander

White

8 SEX Male Female

9A. PARENT/ MOTHER'S NAME AT HER BIRTH

First Full Middle Name Last

B. PARENT/ MOTHER'S SOCIAL SECURITY NUMBER (See instructions for 9 B on Page 3)

Unknown

10A. PARENT/ FATHER'S NAME

First Full Middle Name Last

B. PARENT/ FATHER'S SOCIAL SECURITY NUMBER (See instructions for 10B on Page 3)

Unknown

11Has the person listed in item 1 or anyone acting on his/her behalf ever filed for or received a Social Security number card before?

Yes (If "yes" answer questions 12-13) No Don't Know (If "don't know," skip to question 14.)

12Name shown on the most recent Social Security card issued for the person listed in item 1

First Full Middle Name Last

13 Enter any different date of birth if used on an earlier application for a card MM/DD/YYYY

14 TODAY'S DATE MM/DD/YYYY 15 DAYTIME PHONE

NUMBER Area Code Number

16 MAILING ADDRESSDo Not Abbreviate

Street Address, Apt. No., PO Box, Rural Route No.

City State/Foreign Country ZIP Code

17I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best to my knowledge.

YOUR SIGNATURE 18 YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS:Self Natural Or

Adoptive Parent Legal Guardian Other Specify

DO NOT WRITE BELOW THIS LINE (FOR SSA USE ONLY )NPN DOC NTI CAN ITV

PBC EVI EVA EVC PRA NWR DNR UNIT

EVIDENCE SUBMITTED SIGNATURE AND TITLE OF EMPLOYEE(S) REVIEWING EVIDENCE AND/OR CONDUCTING INTERVIEW

DATE

DCL DATE

- -

- -

( )

Destroy Prior Editions

- -

Change a Record

For marriage certificate changes, contact the county register of deeds

(N.C. Institute of Government website) where the marriage license was

issued.

For divorce certificate changes, contact the county clerk of court where

the divorce was filed.

Birth Certificates

(An appointment is required if customer needs in-person assistance to

change or correct a record)

N.C. Vital Records can assist with changes to a birth or death certificate. Our

office does not handle changes to marriage or divorce certificates.

After acceptance for registration by the State Registrar, no birth certificate can

be altered or changed except by a request. The State Registrar adopts rules

governing the form of these requests and the type and amount of proof required.

This service is available at the county register of deeds where the birth

occurred or through N.C. Vital Records by mail or by appointment. (See phone

numbers below for each type of change). Some county registers of deeds will

provide this service for out-of-county vital events, so please check with your

local register of deeds office for services provided.

To begin the process to change a birth certificate, mail us the Request to Amend

a Record form with a $24 search fee (nonrefundable). Note on the form what

type of change is needed.

Paternity determinations (919-792-5989)

Legitimation actions (when the natural father marries the mother after the

birth of the child) (919-792-5988)

Court-ordered name change (919-792-5985)

Birth certificate after adoption (919-792-5987)

Other amendments (919-792-5986)

Paternities (919-792-5989)

Legitimations (919-792-5988)

After we receive your form with the requested change and the fee, we will

evaluate your request and respond in writing with further instructions.

Changes to a birth certificate include:

A paternity acknowledgment is a legal action that determines the biological

parentage of a child. Paternity may be established through voluntary

acknowledgment by the father and the mother or by court order. There is no fee

for processing a paternity action.

A legitimation is a legal process for biological fathers to acknowledge their

children when they marry the mother after the birth of the child. A new birth

certificate may be issued reflecting the father's name and the child's name can be

changed to the father's last name if the parents agree and request the change.

There is a nonrefundable fee of $15 to process the legitimation request, an

additional charge of $24 for the first copy of the requested certificate, and $15

more for each additional copy of the same certificate. There are charges for

faster service.

In some cases, a court order may be required.

You may also contact the county register of deeds in the county of birth for

assistance.

Court-Ordered Name Changes (919-792-5985)

Birth Certificates after Adoption (919-792-5987)

Changes to Death Certificates (919-792-5986)

An amended birth certificate reflecting a name change ordered by the courts may

be processed for individuals who are born in North Carolina. Please complete

the birth certificate application form providing the information to locate the

original birth certificate. You must include a certified copy of the name change

court order along with your request. There is a fee of $15 to process the name

change, an additional charge of $24 for the first copy of the requested

certificate, and $15 more for each additional copy of the same certificate. There

are charges for faster service.

A new birth certificate with the adoptive information may be processed for

individuals who are born in North Carolina. Please complete the birth certificate

application form providing all adoptive information for the child and the

parents. There is a nonrefundable processing fee of $15 for the preparation of

the new birth certificate. To receive a certified copy of the new birth certificate,

there is an additional charge of $24 for the first copy of the requested certificate

and $15 more for each additional copy of the same certificate. There are charges

for faster service.

Certified copies of an adopted person's birth certificate are available only to

the adoptee, the adoptive parents, the adoptee's children, and the adoptee's

spouse, brothers, and sisters (proof of relationship may be required). The terms

"parent," "brother" and "sister" mean the adoptive parent, brother, or sister.

Those terms do not mean a natural parent, brother, or sister. Original birth

certificates of adoptees showing the adoptee's original name and the birth

mother's name are in legally sealed files and are not available.

After acceptance for registration by the State Registrar, no death certificate can

be altered or changed except by a request. The State Registrar adopts rules

Changes to Fetal Death Reports

Other Amendments or Changes (919-792-5986)

governing the form of these requests and the type and amount of proof required.

This service is available at the county register of deeds where the death

occurred or through N.C. Vital Records by mail or by appointment.

To begin the process to change a death certificate, mail us the Request to Amend

a Record form with a $24 search fee (nonrefundable). Note on the form what

type of change is needed.

After we receive your form with the requested change and the fee, we will

evaluate your request and respond in writing with further instructions.

If you use the county register of deeds office instead, they will advise you of

their procedures and fees.

After acceptance for registration by the State Registrar, no fetal death report can

be altered or changed except by a request. The State Registrar adopts rules

governing the form of these requests and the type and amount of proof required.

This service is available through N.C. Vital Records by mail or by appointment.

To begin the process to change a fetal death report, please contact one of our

representatives at (919) 792-5986 for further assistance or mail in the

completed and signed fetal death report application form with the requested

changes and a $24 search fee (nonrefundable).

In accordance with General Statute 130A-114, parents may also request a

Certificate of Birth Resulting in Stillbirth for events occurring July 1, 2001-

forward. If the fetal death occurred in North Carolina prior to 2001, the State

Registrar may not issue a certificate of birth resulting in stillbirth unless the

customer's application for the certificate is accompanied by a certified copy of

the fetal death report.

If you have another change to make to a birth or death certificate, please contact

us at the phone number above, or mail in your request for changes along with

the search fee.

North Carolina Department of Health and Human Services Division of Public Health • Vital Records Unit

http://vitalrecords.nc.gov/vitalrecords Telephone: 919-733-3000

Mail: 1903 Mail Service Center Location: 225 North McDowell St. Raleigh, NC 27699-1903 Raleigh, NC 27603-1382

PleaSe PRiNT Application for a Copy of a North Carolina Birth CertificateCertificate Information

Full Name on Certificate(If adopted, provide new information)

_________________________________________________________________ First Name Middle Name Last Name

Date of Birth ____ | ____ | ________ Month Day Year

Sex Male FemaleWere parents married at time of

birth? Yes NoIs this person deceased? Yes No

Place of Birth _________________________________________ City County

Full Maiden Name of Mother(Adoptive mother, if applies)

_____________________________________________________________ First Name Middle Name Last Name (before any marriage)

Full Name of Father(Adoptive father, if applies)

_____________________________________________________________ First Name Middle Name Last Name

Check all boxes that apply; add the fees in 1–3 and place the total amount in #4.

See further instructions on Page 2.Your Relationship to the Person Whose Certificate is Requested:

(Check one)1. Order Certificate

Processing times vary. Check website for current information.(Non-refundable fee)

Certificate Search and First Copy ($24) $_______ #___ additional copies x $15 $_______ Certified (Legally suitable for any purpose) Uncertified (Suitable for research purposes)

Self Spouse (Current) Brother/Sister Child Parent/Step-Parent

Authorized agent, attorney or legal representative of the person listed (Proof RequiRed)

Other (may not be entitled to a certified copy)

(Please Print)Requestor: ____________________________________________________________ Print Name of Person Requesting a Certificateaddress: ____________________________________________________________ Street Address (P.O. Box cannot be used for expedited shipping)_______________________________________________________________________ P.O. Box (If mailing to a P.O. Box, street address must also be listed above)_______________________________________________________________________ City, State, Zip Code_______________________________________________________________________ (Area Code) Telephone Number (During business hours)

email address: _________________________________________________________

Payment: Please pay with a cashier’s check or money order made payable to N.C. Vital Records. Personal checks are not accepted. Requests that are submitted with no payment, or incomplete payment or incomplete information will be returned. Credit card payment is available for walk-in customers.

ID Of tHe PeRsON ReqUestINg A CeRtIfICAte Is ReqUIReD: See Page 2 for a list of acceptable IDs. Requests that do not include proper identification will be returned.

2. Record Changes (Only if applies)Appointment required for in-person services. ($15 non-refundable processing fee)

Adoption $_______ Amendment $_______ Name Change $_______ Legitimation Court Order $_______ Legitimation (mother married father after child’s birth) $_______ Paternity (no fee) $ 00.00 Other _____________________ $_______

3. Faster Service (Choose only one)Optional for mail-in requests ($15 non-refundable expedite fee)

Walk-in Service ($15) $_______ Expedited Processing ($15) $_______ (Shipped by regular mail) Expedited Processing and Expedited Shipping ($35) $_______ (No Post Office box delivery)

4. Total Fees (Add 1+2+3 above for total) $_______

i hereby certify that all the above information is true to the best of my knowledge. Note: it is a felony violation of N.C. law (g.s. 130A-26a) to make a false statement on this application or to unlawfully obtain a copy or a certified copy of a birth certificate.___________________________________________________________ _________________________________________ Signature of Person Requesting a Certificate Date

Office Use Only: SFN _______________________________ DCN _____________________________ Cartridge/Frame _________________________________Amount received: $_______________________ Identification presented_________________________________________________________________________Request number ___________________________________________ Request date _______________________________________________________________

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Grandparent

How do you plan to use this record?

DHHS-VR-B (Revised 01/13) N.C. Vital Records (Review 01/16)

Order CertificateA certificate search costs $24 and includes one copy if the certificate is located. The search covers a three year period. Requests are processed in the order received and can take up to five weeks plus the mail delivery time. The search fee is required to process a request and is non-refundable even if a record cannot be located.

Record ChangesComplete this section only if you are making a request to change information on the birth certificate. The $15 processing fee to review your request is non-refundable. In-person assistance for this service is by appointment only. Please call (919) 792-5986 to schedule an appointment. If your request involves more than one birth record, the $15 processing fee applies to each individual’s birth record that requires change(s).

Faster ServiceTo receive expedited service you MUst write “expedite” on the outside of the envelope. Expedited requests will be processed within 10 business days. This does not include the additional day(s) for shipping. This is a non-refundable fee.

Identification RequirementDue to identity theft and other fraudulent use of vital records, ID of the person requesting a certificate is ReqUIReD. Requests that do not include ID will be returned. You MUst include a legible photocopy of one of the photo IDs listed below with your request:

Current state-issued driver’s license (address must match requestor’s address on application)•Current state-issued non-driver photo ID card (address must match requestor’s address on application)•Current Passport or Visa (must include photo)•Current U.S. military ID•Current Department of Corrections photo ID card dated within the last year•Current state or U.S. government agency photo ID card (for persons requesting certificates as part of that •agency’s business)Current student ID card with copy of transcript•

(must be two DIFFERENT forms of ID):Temporary driver’s license•Current utility bill with current address•Car registration or title with current address•Bank statement with current address•Pay stub with current address•Income tax return/W-2 form showing current address•Letter from government agency dated within the last six months and showing current address•State-issued concealed weapon permit showing current address•

If you are unable to meet our ID requirements, a family member or other person who is entitled to obtain the certificate, and who can meet the ID requirements, may request it.

A list of persons entitled to obtain certificates is located on our website at http://vitalrecords.nc.gov/faqs.htm.

DHHS-VR-B (Revised 01/13) N.C. Vital Records (Review 01/16)

If you do not have one of the IDs listed above, you must provide legible photocopies of TWO of the following

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Voter Registration as of 03/26/2013 Democratic: 2,767,193 Republican: 1,980,869 Libertarian: 20,431 Unaffiliated: 1,658,013 Total: 6,426,506

Quick Links

Changing your voter registration in North Carolina

Changing your voter registration information - including, but not limited to name, residential address, mailing address, or party

affiliation, is simple.

How?

The North Carolina Voter Registration Application, found on this website, or a written notice, may be used to change any voting

information, including: name, address and party affiliation. The change notification must be signed, and should be sent to the

appropriate County Board of Elections by the voter registration deadline.

What if I've moved?

When you move within a county, you should complete an in-county change of address. This can be completed on your voter

identification card, a signed letter to your local board of elections, or on the form specified above.

When you move from one county to another, you will need to apply for voter registration in your new county of residence. Use the

form specified above, request that an application be mailed to you, or pick up a form at any local board of elections or public

library. Note that when you move within the State, the law requires that you update the address on your driver's license within 60

days. When you obtain a duplicate drivers license, you may also elect to update your voter registration information as well.

Note that if you move during a time close to an election, the following rules apply:

If you have moved more than 30 days prior to the election, you will need to update your registration with your new address

(or if applicable, register to vote in your new county of residence) no later than 25 days prior to the election. You will then

be registered and may possibly have a new polling location. On election day, if you failed to update your voter registration,

you may still vote at your new polling location, as long as you have not moved out of the county of your existing

registration. Since your move was unreported, you may be asked to vote a provisional ballot.

If you have moved fewer than 30 days prior to the election, you are still qualified to vote in your prior polling place and may

vote only there, even if you moved outside of your county.

It is important that the board of elections is able to contact you by mail to inform you of changes to your polling place and/or

voting districts, so be sure to notify the board of any changes to your mailing address.

What about other changes?

If you need to make other changes to your voter record (name change, party affiliation change, etc.), you may use the voter

registration application, the form on your voter registration card, or simply send your county board of elections a note or letter. No

change may be made without your signature. Note, in a partisan primary, a voter who is registered with a political party may only

participate in that party’s primary. Voters who are registered as unaffiliated may participate in the primary of any political party

that has opened its primary to unaffiliated voters. North Carolina’s three recognized political parties have all opened their

primaries to unaffiliated voters.

How will I know the change has been made to my record?

Once you have completed and mailed your changes to your local board of elections, allow two to six weeks for delivery of your

voter identification card. Read the information thoroughly and note any changes or mistakes on the card. A voter identification

card is for your use only, you do not need the card in order to vote.

North Carolina State Board of Elections • 441 North Harrington Street, Raleigh, NC 27603 • (919) 733-7173

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version092009-web Complete, sign and mail this form to your County Board of Elections Office. Be sure to affix the proper USPS postage.

06wNORTH CAROLINA VOTER REGISTRATION APPLICATIONPlease use black or blue ink and print legibly.

FOR OFFICE USE ONLY

Date Received

1 Are you a citizen of the United States of America? Yes No Will you be at least 18 years of age on or before election day? Yes No

IF YOU CHECKED "NO" IN RESPONSE TO THIS QUESTION, DO NOT SUBMIT THIS FORM.

Are you at least 16 years of age and understand that you must be 18 years of age on or before election day to vote?

Yes No

IF YOU CHECKED "NO" IN RESPONSE TO BOTH OF THESE QUESTIONS ABOVE, DO NOT SUBMIT THIS FORM.

2 Last Name (Required) First Name (Required)

Middle Name (Required) Date of Birth MMDDYYYY (Required)

Jr Sr II

III IV V

If you know your NC Voter Registration Number, please enter it here: County of Birth State of Birth

M M D D Y Y Y Y

3 Do you have a NC Driver's License or DMV-issued identification card? If yes, provide the number. Yes No

If you do not have a NC DMV-issued license or ID card, do you have a Social Security Number? If yes, provide the last 4 digits.

Yes No X X X X X- -

RESIDENTIAL ADDRESS INFORMATION (STREET ADDRESS WHERE YOU LIVE) - No P.O. Boxes or Rural Routes

4 Street Address where you live (Required) Apartment, Lot, or Unit Number

City (Required) Zip Code

County

Have you lived here for 30 days or more?

Yes No If "No," date moved? MMDDYYYY Phone (Optional)

N CState

MAP/DIAGRAM If you do not have a street address, draw a map of where you reside. Please include roads and landmarks.

MAILING ADDRESS

5 Mailing Address (If different from your residential address)

City State Zip Code

6 GENDER RACE ETHNICITY POLITICAL PARTY AFFILIATION

Female

Male

African American/ Black

Asian

White

American Indian/ Alaska Native

Multiracial

Other

Hispanic/Latino

Not Hispanic/ Latino

Democrat Republican Libertarian

Unaffiliated Other

If you indicate a political party that is not currently qualified or you do not indicate a choice, you will be listed as "Unaffiliated."

PREVIOUS REGISTRATION (Name & Address used for your last voter registration - If applicable)

7 Last Name used in Previous Registration First Name

Previous Address State Zip Code

Previous City Previous County

I Attest, under penalty of perjury, that in addition to having read and understood the contents of this form, that: · I am a United States citizen, as indicated above; · I am at least 18 years old, or will be at the time of the next general election, or I am at least 16 years old and understand that I must be at least 18 years old on Election Day of the general election in order to vote; · I shall have been a resident of North Carolina, this county, precinct, or other election district for 30 days before the election in which I intend to vote; · I will not vote in any other county or state after submission of this form and if I am registered elsewhere, I am canceling that registration at this time; and · I have not been convicted of a felony, or if I have been convicted of a felony, I have completed my sentence, including any probation or parole. (Citizenship and voting rights are automatically restored upon completion of the sentence. No special document is needed.)

Signature (Required) Date

WARNING: If you sign this form and know it to be false, you can be convicted of a Class I felony.

Change Your Name in Your U.S. Passport

IF THEN

Your passport was issued less than 1

year ago

and

Your name has been legally changed

due to marriage or court order

You must mail:

Your current, valid U.S. passport

Completed Form DS-5504,

Application for a U.S. Passport: Name

Change, Data Correction, and Limited

Passport Book Replacement

An original or certified copy of

your marriage certificate or the

government-issued document

evidencing your legal name change

under federal or state law.

If required, one recent, color

photo (details)

to the address listed on Form DS-

5504 .

IMPORTANT NOTES:

There is no fee for this service unless you require Expedited Service .

We strongly encourage you to mail your passport application and any

personal documents using a traceable delivery method.

In order to protect the contents of your mailing from the elements throughout

the delivery process, we strongly encourage you to mail your passport

application and any personal documents using a secure means of packaging,

such as a Tyvek envelope.

IF THEN

You must mail:

Your current, valid U.S. passport

Your passport was issued more than 1

year ago

and

Your name has been legally changed

due to marriage or court order

Completed Form DS-82,

Application for a U.S. Passport by Mail

Applicable "Renewal" fees

An original or certified copy of

your marriage certificate or the

government-issued document

evidencing your legal name change

under federal or state law.

One recent, color photograph

to the address listed on Form DS-

82.

IMPORTANT NOTES:

Minors may not apply using Form DS-82 and should refer to the instruction

below.

We strongly encourage you to mail your passport application and any

personal documents using a traceable delivery method.

In order to protect the contents of your mailing from the elements throughout

the delivery process, we strongly encourage you to mail your passport

application and any personal documents using a secure means of packaging,

such as a Tyvek envelope.

IF THEN

If you cannot legally document your

name change (through court order or

marriage)

or

If you are a minor under age 16 whose

passport was issued more than one year

ago.See Special Requirements for All

Minors Under Age 16.

You must submit the following in

person at an Acceptance Facility or

a Passport Agency :

Your current, valid U.S. passport

A completed Form DS-11,

Application for a U.S. Passport

Applicable "First Time" fees

At least 3 public records showing

your

date and place of birth that show

exclusive use of your assumed name

for at least 5 years

One recent, color photograph

If you answered no to any of the above statements you are

not eligible to use Form DS-82! You must follow the instructions

on How to Apply for the First Time (In Person).

Passport by Mail: DS 82

SUBMIT FORM DS-82 IF ALL OF THE FOLLOWING ARE TRUE:

Your Most Recent U.S. Passport:

Is undamaged and can be submitted with your application

Was issued when you were age 16 or older

Was issued within the last 15 years

Was issued in your current name or you can legally

document your name change

STEPS TO SUBMITTING FORM DS-82:

Read and understand Steps 1-3 before leaving this page.

STEP 1: Complete and Print Form

Enter your information online

and print Form DS-82. Print the

completed form using black ink

on one-sided pages.

Print a blank Form DS-82 and

complete by hand. Print the form

on one-sided pages and

complete with black ink.

Complete Online & Print Complete by Hand

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.

Form DS-82 can also be obtained from your local Acceptance Facility or a

Passport Agency.

STEP 2: Sign and Date

You must sign and date Form DS-82 on page 1 of the application.

STEP 3: Submit Completed Form + Additional Documents

Mail Form DS-82 in a padded envelope to the address listed on the form, along

with:

Your most recent U.S. Passport (book or card)

One Passport Photo that is stapled to the application within the space

provided using four vertical staples, one in each corner

Current Passport Fees

A marriage certificate or court order (only if your current name is different from

what was recorded in your most recent U.S. passport)

NOTES:

We strongly encourage you to mail your passport application and any personal

documents using a traceable delivery method.

Please do not submit any prepaid return mailing envelopes or mailing stamps.

Newly issued Passport Books are delivered via Priority Mail with Delivery

Confirmation, unless you pay for overnight delivery return service at time of

application. Overnight delivery service is not available for passport cards, which

are delivered via First Class Mail only.

In order to protect the contents of your mailing from the elements throughout

the delivery process, it is strongly recommended that you mail your passport

application and personal documents in an envelope large enough to fit the

application without folding. Please do not use a standard letter-size #10 (4

1/8" x 9 1/2") envelope.

For more information, please see Helpful Hints for Submitting Form DS-82.

If You Wish to Expedite Your Passport Application:

Include a check or money order for $60.00 made payable to the U.S.

Department of State. Do not send cash in the mail (See Passport Fees)

Clearly mark ‘EXPEDITE’ on the outside of the padded envelope

We recommend using an overnight delivery service for delivery to and from the

Passport Agency

See Application Processing Times and How to Get a Passport in a Hurry for more

information.

NEED A U.S. PASSPORT IMMEDIATELY?

You should make an appointment to be seen at a Regional Passport Agency only if:

The U.S. passport is needed in less than 2 weeks for international travel

The U.S. passport is needed within 4 weeks to obtain a foreign visa

Contact the National Passport Information Center to make an appointment or locate a

Passport Agency.

If you are overseas and need to apply for or renew your U.S.

passport, please follow the instructions under the U.S. passport

section in Tips for Americans Traveling Abroad.

U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS

PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS

CAN I USE THIS FORM?Complete the checklist to determine your eligibility to use this form

Yes

If you answered NO to any of the statements above,STOP - You cannot use this form!

You must apply on application form DS-11 by making a personal appearance before an acceptance agentauthorized to accept passport applications. Visit travel.state.gov to find your nearest acceptance facility.

Yes

Yes

Yes No

No

No

No

Yes No

--OR--

Date of Application:_____________________

U.S. PASSPORTS, EITHER IN BOOK OR CARD FORMAT, ARE ISSUED ONLY TO U.S. CITIZENS OR NON-CITIZEN NATIONALS. EACH PERSONMUST OBTAIN HIS OR HER OWN PASSPORT BOOK OR PASSPORT CARD. THE PASSPORT CARD IS A U.S. PASSPORT ISSUED IN CARDFORMAT. LIKE THE TRADITIONAL PASSPORT BOOK, IT REFLECTS THE BEARER'S ORIGIN, IDENTITY, AND NATIONALITY AND IS SUBJECTTO EXISTING PASSPORT LAWS AND REGULATIONS. UNLIKE THE PASSPORT BOOK, THE PASSPORT CARD IS VALID ONLY FOR ENTRY TOTHE UNITED STATES AT LAND BORDER CROSSINGS AND SEA PORTS OF ENTRY WHEN TRAVELING FROM CANADA, MEXICO, THECARIBBEAN, AND BERMUDA. THE U.S. PASSPORT CARD IS NOT VALID FOR INTERNATIONAL AIR TRAVEL.

Please visit our website at travel.state.gov. In addition, you may contact the National Passport InformationCenter (NPIC) toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) or by email at NPIC@state.gov. CustomerService Representatives are available Monday-Friday 8:00a.m.-10:00p.m. Eastern Time (excluding federalholidays.) Automated information is available 24/7.

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 ABROADUnited States citizens residing abroad CANNOT submit this form to the domestic address listed on the Instruction Page 2. Such applicants should contact thenearest U.S. embassy or consulate for procedures to be followed when applying overseas.

DS-82 12-2010 Instruction Page 1 of 4

WARNING: False statements made knowingly and willfully in passport applications, including affidavits or other documents submitted to supportthis application, are punishable by fine and/or imprisonment under U.S. law, including the provisions of 18 USC 1001, 18 USC 1542, and/or 18 USC1621. Alteration or mutilation of a passport issued pursuant to this application is punishable by fine and/or imprisonment under the provisions of18 USC 1543. The use of a passport in violation of the restrictions contained therein or of the passport regulations is punishable by fine and/orimprisonment under 18 USC 1544. All statements and documents are subject to verification.

See page 2 of the instructions for detailed information on the completion and submission of this form.

I can submit my most recent U.S. passport book and/or U.S. passport card with this application.

I was at least 16 years old when my most recent U.S. passport bookand/or passport card was issued.

I was issued my most recent U.S. passport book and/or passport card less than 15 years ago.

My most recent U.S. passport book and/or U.S. passport card for which I am renewing has not been lost, stolen, mutilated, or damaged.

I use the same name as on my recent U.S. passport book and/orU.S. passport card.

I have had my name changed by marriage or court order and cansubmit proper documentation to reflect my name change.

FOR INFORMATION, QUESTIONS, AND INQUIRIES:

Your most recent U.S. passport book and/or U.S. passport card;

A certified copy of your marriage certificate or court order if your name has changed;

Fees; and

A recent, color photograph.

1. YOUR MOST RECENT U.S. PASSPORT (BOOK AND/OR CARD FORMAT).

Submit your most recently issued passport book and/or passport card. When submitting a passport book and/or passport card with this form, please verifythat the document was issued at age 16 or older in your current name (or see item #2 below) and issued within the past 15 years. If your U.S. passport has beenlost, stolen, damaged, or mutilated, you must apply on the DS-11 application form as specified below.

2. A MARRIAGE CERTIFICATE OR COURT ORDER.

If the name you are currently using differs from the name on your most recent passport, you must submit a certified copy of your marriage certificate or courtorder showing the change of name. All documents will be returned to you by mail. If you are unable to document your name change in this manner, you mustapply on the DS-11 application form by making a personal appearance at (1) a passport agency; (2) U.S. embassy or consulate, if abroad; (3) any federal orstate court of record or any probate court accepting passport applications; (4) a designated municipal or county official; or (5) a post office which has beenselected to accept passport applications.

3. THE CURRENT PASSPORT FEE.

Enclose the fee in the form of a personal check or money order. MAKE CHECKS PAYABLE TO "DEPARTMENT OF STATE." THE FULL NAME ANDDATE OF BIRTH OF THE APPLICANT MUST BE TYPED OR PRINTED ON THE FRONT OF THE CHECK. DO NOT SEND CASH. Passport Servicescannot be responsible for cash sent through the mail. By law, the fees are non-refundable. Please visit our website at travel.state.gov for detailed informationregarding current fees.

OVERNIGHT DELIVERY SERVICE: If you desire overnight delivery service for the return of your passport, please include the appropriate fee with yourpayment. FASTER PROCESSING: For an additional fee, you may request expedited service. Please include this fee in your payment and submit the application to theappropriate address. Please write "Expedite" on the outer envelope when mailing. Also, TO ENSURE MINIMAL PROCESSING TIME for expeditedapplications, Passport Services recommends using overnight delivery when submitting the application AND including the appropriate postage fee forreturn overnight delivery for the completed passport book or passport card. Expedited service is available only in the United States. Please visit travel.state.gov for updated information regarding fees, processing times, or to check the status of your passport application online.

4. A RECENT, COLOR PHOTOGRAPH.

Submit a color photograph of you alone, sufficiently recent to be a good likeness of you (taken within the last six months), and 2x2 inches in size. The imagesize measured from the bottom of your chin to the top of your head (including hair) should not be less than 1 inch and not more than 1 3/8 inches. Thephotograph must be color, clear, with a full front view of your face, and printed on thin paper with plain light (white or off-white) background. The photographmust be taken in normal street attire, without a hat, head covering, or dark glasses unless a signed statement is submitted by the applicant verifying the item isworn daily for religious purposes or a signed doctor's statement is submitted verifying the item is used daily for medical purposes. Headphones, "bluetooth", orsimilar devices must not be worn in passport photographs. Any photographs retouched so that your appearance is changed are unacceptable. Snapshots, mostvending machine prints, and magazine or full-length photographs are unacceptable. Digitized photos must meet the previously stated qualifications and will beaccepted for use at the discretion of Passport Services. Please visit our website at travel.state.gov for details and information.

WHAT DO I SEND WITH THIS APPLICATION FORM?

WHERE DO I MAIL THIS APPLICATION?

FOR ROUTINE SERVICE:National Passport Processing CenterPost Office Box 90155Philadelphia, PA 19190-0155

FOR EXPEDITED SERVICE (Additional Fee):National Passport Processing CenterPost Office Box 90955Philadelphia, PA 19190-0955

DS-82 12-2010

See below for more detailed information.

Instruction Page 2 of 4

Your most recent U.S. passport book and/or U.S. passport card;

A certified copy of your marriage certificate or court order if your name has changed;

Fees; and

A recent, color photograph.

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 theaddress 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 ofyour new passport, please contact the National Passport Information Center.

NOTE: You may receive your newly issued document and your returned citizenship evidence in separate mailings. If you are applying for both a passport bookand card you may receive three separate mailings; one with your returned citizenship evidence; one with your newly issued passport book, and one with yournewly printed passport card.

If you choose to provide your email address in Item #6 on this application, Passport Services will use that information to contact you in the event there is aproblem with your application or if you need to provide information to us.

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

DS-82 12-2010

FEDERAL TAX LAW

Section 6039E of the Internal Revenue Code (26 USC 6039E) requires you to provide your Social Security Number (SSN), if you have one, whenyou 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 areresiding abroad, you must also provide the name of the foreign country in which you are residing. The Department of State must provide your SSNand foreign residence information to the Department of Treasury. If you fail to provide the information, you are subject to a $500 penalty enforcedby the IRS. All questions on this matter should be directed to the nearest IRS office.

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 accountinformation on it to electronically debit your account for the amount of the check. The debit from your account will usually occur within 24 hours andwill 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 processedfor technical reasons, you authorize us to process the copy in place of your original check. If the EFT cannot be completed because of insufficientfunds, 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.

NOTICE TO CUSTOMERS APPLYING OUTSIDE A STATE DEPARTMENT FACILITY

Passport service fees are established by law and regulation (see 22 USC 214, 22 CFR 22.1, and 22 CFR 51.50-56) and are collected at the timeyou apply for the passport service. If the Department fails to receive full payment of the applicable fees because, for example, your check isreturned for any reason or you dispute a passport fee charge to your credit card, the Department of State will take action to collect the delinquentfees from you under 22 CFR Part 34 and the Federal Claims Collection Standards (see 31 CFR Parts 900-904). In accordance with the DebtCollection Improvement Act (Pub.L. 104-134), if the fees remain unpaid after 180 days and no repayment arrangements have been made, theDepartment will refer the debt to the Department of Treasury for collection. Debt collection procedures used by Treasury may include referral of thedebt to private collection agencies, reporting of the debt to credit bureaus, garnishment of private wages and administrative offset of the debt byreducing 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. Aninvalidated passport cannot be used for travel.

REMITTANCE OF FEES

Your Social Security Number will be provided to Treasury, used in connection with debt collection and checked against lists of persons ineligible orpotentially ineligible to receive a U.S. passport, among other authorized uses.

OTHER USES OF SOCIAL SECURITY NUMBERS

PAPERWORK REDUCTION STATEMENT

Public reporting burden for this collection of information is estimated to average 40 minutes per response, including the time required for searchingexisting 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 this collection displays a currently valid OMB control number. If you have comments on theaccuracy of this burden estimate and/or recommendations for reducing it, please send them to: A/GIS/DIR, Room 2400 SA-22, U.S. Department ofState, Washington, DC 20520-2202.

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 validU.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 newapplication, it is necessary to submit a Form DS-64, Statement Regarding a Lost or Stolen Passport. Your statement must detail why the previousU.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 StolenPassport System. This system is designed to prevent the misuse of your lost or stolen U.S. passport book or passport card. Anyone using thepassport book or passport card reported as lost or stolen may be detained upon entry into the United States. Should you locate the U.S. passportbook 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 notuse 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.

Instruction Page 3 of 4

DS-82 12-2010

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.) Ihave not, since acquiring United States citizenship/nationality, been naturalized as a citizen of a foreign state; taken an oath or made an affirmationor other formal declaration of allegiance to a foreign state; entered or served in the armed forces of a foreign state; accepted or performed theduties of any office, post, or employment under the government of a foreign state or political subdivision thereof; made a formal renunciation ofnationality 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 courtor court martial of competent jurisdiction of committing any act of treason against, or attempting by force to overthrow, or bearing arms against, theUnited States, or conspiring to overthrow, put down, or to destroy by force, the government of the United States.

Furthermore, I have not been convicted for a federal or state drug offense or convicted for "sex tourism" crimes statute and I am not the subject ofan outstanding federal, state or local warrant of arrest for a felony; a criminal court order forbidding my departure from the United States; asubpoena received from the United States in a matter involving federal prosecution for, or grand jury investigation of, a felony.

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, and otherapplicable laws and regulations, including 22 USC 211a et seq.; 8 USC 1104; 26 USC 6039E, Section 236 of the Admiral James W. Nance andMeg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001; Executive Order 11295 (August 5, 1966); and 22 CFR parts 50and 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 and privatecontractors to assist the U.S. Department of State in adjudicating 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 toforeign government agencies to fulfill passport control and immigration duties. The information may also be provided to foreign governmentagencies, international organizations and, in limited cases, private persons and organizations to investigate, prosecute, or otherwise addresspotential violations of law or to further the Secretary's responsibility for the protection of U.S. citizens and non-citizen nationals abroad. Theinformation may be made available to the Department of Homeland Security and private employers for employment verification purposes. For amore detailed listing of the routine uses to which this information may be put see the Department of State's Prefatory Statement of Routine Usesrelative to the Privacy Act (Public Notice 6290 of July 15, 2008) and the listing of routine users set forth in the System of Records Notices forOverseas Citizen Services Records (State-05) and Passport Records (State-26) published in the Federal Register.

Your social security numbers will be provided to the U.S. Department of Treasury and failure to provide it may subject you to a penalty, as describedin the Federal Tax Law provision. It also may be used for identification verification for passport adjudication and in connection with debt collection,among other purposes as authorized and generally described in this section. Providing your social security number and other information requestedon this form otherwise is voluntary, but failure to provide the information requested on this form may result in processing delays or the denial of yourU.S. passport application.

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Failure to provide the information requested on this form may result in PassportServices' refusal to accept your application or result in the denial of a U.S. passport.

ELECTRONIC PASSPORT STATEMENT

The Department of State now issues a type of passport book containing an embedded electronic chip and called an "Electronic Passport". Theelectronic passport book continues to be proof of the bearer's United States citizenship/nationality and identity, and looks and functions in the sameway as a passport without a chip. The addition of an electronic chip in the back cover enables the passport book to carry a duplicate electroniccopy of all information from the data page. The electronic passport book is usable at all ports-of-entry, including those that do not yet haveelectronic chip readers.

Use of the electronic format provides the traveler the additional security protections inherent in chip technology. Moreover, when used atports-of-entry equipped with electronic chip readers, the electronic passport book provides for faster clearance through some of the port-of-entryprocesses.

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 fromunauthorized reading.

The cover of the electronic passport book is printed with a special symbol representing the embedded chip. The symbol will appear inport-of-entry areas where the electronic passport book can be read.

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 SPONSORINGAGENCY FOR INSTRUCTIONS ON PROPER ROUTING PROCEDURES BEFORE FORWARDING THIS APPLICATION. Your completedpassport will be released to your sponsoring agency for forwarding to you.

Instruction Page 4 of 4

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 theapplication are true and correct; 3) I have not knowingly and willfully made false statements or included false documents in support of this application; 4) the photographsubmitted with this application is a genuine, current photograph of me; and 5) I have read and understood the warning on page one of the instructions to the application form.

YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW

* DS 82 C 12 2010 1 *OtherPostageEFBk Fee Cd Fee

ST

AP

LE 2" x 2" S

TA

PL

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2"

x 2

"

S

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xDateApplicant's Signature

FOR ISSUING OFFICE ONLYMarriage Certificate

Court Order

From

Date of Marriage/Place Issued:

Date Filed/Court:

Attached:

U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS OMB APPROVAL NO. 1405-0020EXPIRATION DATE: 12-31-2013ESTIMATED BURDEN: 40 MINPlease Print Legibly Using Black Ink Only

End. # Exp.

DS-82 12-2010

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To:

DOTS CodeDPOD

CONTINUE TO PAGE 2

Page 1 of 2

For Issuing Office Only

Attention: Read WARNING on page 1 of instructions Please select the document(s) for which you are applying:

U.S. Passport Book U.S. Passport Card

28 Page Book (Standard)Note: The 52 page option is for those who frequently travel abroad during the passport validity period and is recommendedfor applicants who have previously required the addition of visa pages.

A. B.

City Zip Code Country, if outside the United StatesState

9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed)

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)

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

First Middle

- - M F3. Sex

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

@

7. Primary Contact Phone Number5. Social Security Number

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

-- -

1. Name Last

Issue date (mm/dd/yyyy)Most recent passport book number

10. Passport Book and/or Passport Card InformationYour name as listed on your most recent passport book and/or passport card

11. Name Change Information Complete if name is different than last passport book or passport card

Changed by Marriage

Changed by Court Order

Place of Name Change (City/State)

Please submit a certified copy of your marriage certificate or court order to support your name change.

Most recent passport card number Issue date (mm/dd/yyyy)

PPT C/R PPT S/R

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

Date (mm/dd/yyyy)

Both

52 Page Book (Non-Standard) The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions.

-

Submit a recent,color photograph

17. Additional Contact Phone Numbers

12. Height 14. Eye Color 15. Occupation 16. Employer or School (if applicable)

18. Permanent Address: If P.O. Box is listed under Mailing Address or if residence is different from Mailing Address.

Apartment/Unit

City Zip Code

19. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency.

Name Apartment/Unit

City Relationship

20. Travel Plans

Date of Trip (mm/dd/yyyy) Countries to be visited

Date of Birth (mm/dd/yyyy) Name of Applicant (Last, First & Middle)

STOP! YOU HAVE COMPLETED YOUR APPLICATIONBE SURE TO SIGN AND DATE PAGE ONE

Home Cell

Work

Home Cell

Work

State

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

State Zip Code Phone Number

Duration of Trip

DS-82 12-2010 Page 2 of 2

13. Hair Color

* DS 82 C 12 2010 2 *

Street/RFD # or URB (No P.O. Box)