You are on page 1of 1


Department of State/National Passport Center March 1, 2017

Office of Law Enforcement Liaison
1150 Passport Service PL
4th Floor
Dulles, VA 20189-1150

Regarding: Certified Copy of Passport Application for Full Living Name

To whom it may concern:

I would like to receive a certified copy of my recent application for a passport. Again, I am NOT seeking a certified
copy of my passport but rather the application that I submitted to receive the passport. The application was
submitted with an Explanatory Statement Annexed to the application. Please understand that the word Annex is
a lawful definition meaning to permanently affix to. I am requesting that the Annexed Explanatory Statement be
certified and sent back with the original DS-11 form. Time on insert date and they gave me the following
information that I would have to submit to receive this certified copy. They were unsure as to the fees, so they
told me to pay the $50.00 and leave you with my phone number to contact in case there was more money
required. Reason: For my records purposes.

Given Name: First Name Middle Name / Surname: Last Name

Date Born: Place Born:
Currently receiving mail: c/o Your Address, Costa Mesa, California America [92626]
Date Passport Issued: Passport ID #:

Thank you,

By: ____________________________________
Non Assmupsit, A.R.R., w/o Prejudice

A notary public or other officer completing this certificate verifies only the identity of the individual who signed
the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of this document.
State of California )
) For Verification Purposes Only
______________ County )

On _____________________________ before me, __________________________________________________

Date Here Insert Name and Title of the Officer
Personally appeared surname, given names, who proved to me on the basis of satisfactory evidence to be the
person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they
executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the
instrument the person(s) or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PURJURY under the laws of the State of California that the foregoing paragraph is true
and correct. WITNESS my hand and official seal.

Signature ___________________________________________