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,” which is (DSP-64).

                        Houston Passport Agency

1919 Smith Street

Houston, Texas 77002



Dear Passport Representative,



Please be advised, I, named immediately below...
First Name* 
Middle* 
(or "none" / "unknown")
Last Name* 
Suffix*
(or "none")
...was issued a valid US Passport on:

Date of issuance*
                                            
                                            Month
                                        

                                            
                                            Day
                                        

                                            
                                            Year
                                       
                                   

Please note, my passport has been lost or stolen, and I cannot 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:
Date of Departure*
                                            
                                            Month
                                        

                                            
                                            Day
                                        

                                            
                                            Year
                                       
                                   

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 signed*
                            
                            MM slash DD slash YYYY
                        
                        
*
Please print