U.S. Birth Certificate
5235 Glenmont Drive
Houston Texas 77081
Ph: 888-736-2692
Ph: 713-974-1645

Lost or Stolen Passport Statement
*Note: You must fill this form out if you have lost your passport. This letter will
accompany your "Lost or Stolen Form" (DSP-64).

____________________
Date

Houston Passport Agency
1919 Smith Street
Suite 1100
Houston, Texas  77002

Dear Passport Representative,

Please be advised, I______________________________, was issued a valid US Passport
                                                     (your full name here)

on day:_____________, month:__________________, year:_____________.


Please note, my passport has been lost or stolen and I can not locate it. Please be advised that I now have an urgent immediate international departure from the USA and I need to apply for a new passport. I will be departing from the USA on:________________________.

I am now requesting that you please issue another passport to me, so I can use it for my trip. If in the event while traveling overseas I misplace my passport I will immediately contact the closest US Embassy. If in the event while traveling domestically I misplace my passport I will contact the closest US Passport Office or the US State Department.

Thank you for your assistance in this urgent matter.

Sincerely,

_____________________________________             
Signature


_______________________
  Date





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