Form DS-5504, Passport Correction Instructions
This form contains 93 fields organized into 17 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Applicant Information | ||
| undefined | Text |
Enter the full name of the applicant.
|
| Date of Birth | Text |
Enter the date of birth of the applicant in the format mm/dd/yyyy.
|
| Height | Text |
Enter the height of the applicant in feet and inches.
|
| Hair Color | Text |
Enter the hair color of the applicant.
|
| Eye Color | Text |
Enter the eye color of the applicant.
|
| Occupation | Text |
Enter the current occupation of the applicant.
|
| Employer or School | Text |
Enter the name of the employer or school of the applicant.
|
| Application Type | ||
| Limited_No | CheckBox |
Check this box if you are applying for a limited passport replacement.
|
| Contact Information | ||
| Text |
Enter your email address.
|
|
| App Phone 1 | Text |
Enter the first three digits of your phone number.
|
| App Phone 2 | Text |
Enter the next three digits of your phone number.
|
| App Phone 3 | Text |
Enter the last four digits of your phone number.
|
| Additional Contact Phone Numbers | Text |
Enter any additional contact phone numbers for the applicant.
|
| Additional #_Home | CheckBox |
Check this box if the additional contact number is a home phone.
|
| Additional #_Cell | CheckBox |
Check this box if the additional contact number is a cell phone.
|
| Additional Contact Phone Numbers | Text |
Enter any additional contact phone numbers for the applicant.
|
| Additional # 2_Home | CheckBox |
Check this box if the second additional contact number is a home phone.
|
| Additional # 2_Cell | CheckBox |
Check this box if the second additional contact number is a cell phone.
|
| Additional #_Work | CheckBox |
Check this box if the additional contact number is a work phone.
|
| Additional #_Other | CheckBox |
Check this box if the additional contact number is another type of phone.
|
| Additional # 2_Work | CheckBox |
Check this box if the second additional contact number is a work phone.
|
| Additional # 2_Other | CheckBox |
Check this box if the second additional contact number is another type of phone.
|
| Correction Information | ||
| Printed Incorrectly Last Name | Text |
Enter your last name as it is incorrectly printed on your current passport.
|
| Printed Incorrectly | CheckBox |
Check this box if your name is printed incorrectly on your current passport.
|
| Printed Incorrectly_No | CheckBox |
Check this box if your name is not printed incorrectly on your current passport.
|
| First | Text |
Enter your first name as it is incorrectly printed on your current passport.
|
| undefined | Text |
Enter your middle name as it is incorrectly printed on your current passport.
|
| Corrected Date of Birth | Text |
Enter your corrected date of birth.
|
| Corect Gender_M | CheckBox |
Check this box if your corrected gender is male.
|
| Corect Gender_F | CheckBox |
Check this box if your corrected gender is female.
|
| Corect Gender_X | CheckBox |
Check this box if your corrected gender is non-binary.
|
| undefined | Text |
Enter your corrected place of birth.
|
| Eligibility | ||
| Changed Name_YES | RadioButton |
Select this option if you have changed your name.
|
| Changed Name_NO | RadioButton |
Select this option if you have not changed your name.
|
| Information Printed Incorrectly_YES_2 | RadioButton |
Select this option if the information printed on your passport is incorrect.
|
| Information Printed Incorrectly_NO_2 | RadioButton |
Select this option if the information printed on your passport is correct.
|
| Limited Book Check_YES_3 | RadioButton |
Select this option if you have a limited passport book.
|
| Limited Book Check_NO_3 | RadioButton |
Select this option if you do not have a limited passport book.
|
| Emergency Contact | ||
| Emergency Contact Name | Text |
Enter the name of the emergency contact person.
|
| Emergency Contact Information | ||
| undefined | Text |
Enter the full address of your emergency contact.
|
| undefined | Text |
Enter the apartment or unit number of your emergency contact's address, if applicable.
|
| undefined | Text |
Enter the city of your emergency contact's address.
|
| Emerg State | Text |
Enter the state of your emergency contact's address.
|
| undefined | Text |
Enter the zip code of your emergency contact's address.
|
| undefined | Text |
Enter the phone number of your emergency contact.
|
| undefined | Text |
Specify your relationship to the emergency contact (e.g., spouse, parent, friend).
|
| Form Actions | ||
| Clear | Button |
Click this button to clear the form.
|
| General | ||
| Yes | CheckBox |
Check this box if you answer 'Yes' to the question being asked.
|
| Limited Passport Replacement | ||
| Limited | CheckBox |
Check this box if you are applying for a limited passport replacement.
|
| Mailing Address | ||
| Mailing Address Line 1: Street/RFD#, P.O. Box, or URB | Text |
Enter the first line of your mailing address, including street, RFD#, P.O. Box, or URB.
|
| undefined | Text |
Enter the second line of your mailing address, if applicable.
|
| City | Text |
Enter the city of your mailing address.
|
| App Mailing State | Text |
Enter the state of your mailing address using the two-letter state abbreviation.
|
| Zip Code | Text |
Enter the ZIP code of your mailing address.
|
| City | Text |
Enter the country of your mailing address.
|
| Name Change Information | ||
| Changed Last Name | Text |
Enter your new last name if you have changed it.
|
| Name Change | CheckBox |
Check this box if you are applying for a name change.
|
| Name Change_No | CheckBox |
Check this box if you are not applying for a name change.
|
| First | Text |
Enter your new first name if you have changed it.
|
| undefined | Text |
Enter your new middle name if you have changed it.
|
| Passport Information | ||
| Your name as printed on your most recent U.S. passport book and/or passport card | Text |
Enter your name as printed on your most recent U.S. passport book and/or passport card.
|
| Most recent U.S. passport book number | Text |
Enter the number of your most recent U.S. passport book.
|
| Book Issue Date mm/dd/yyyy | Text |
Enter the issue date of your most recent U.S. passport book in the format mm/dd/yyyy.
|
| Most recent U.S. passport card number | Text |
Enter the number of your most recent U.S. passport card.
|
| Card Issue Date mm/dd/yyyy | Text |
Enter the issue date of your passport card in the format mm/dd/yyyy.
|
| Passport Type | ||
| Selection_Book | CheckBox |
Check this box if you are applying for a passport book.
|
| Selection_Card | CheckBox |
Check this box if you are applying for a passport card.
|
| Selection_Both | CheckBox |
Check this box if you are applying for both a passport book and card.
|
| Regular or Large Book_Regular | CheckBox |
Check this box if you are applying for a regular-sized passport book.
|
| Regular or Large Book_Large | CheckBox |
Check this box if you are applying for a large-sized passport book.
|
| Permanent Address | ||
| undefined | Text |
Enter the street address of the applicant's permanent address.
|
| undefined | Text |
Enter the apartment or unit number of the applicant's permanent address.
|
| City | Text |
Enter the city of the applicant's permanent address.
|
| Permanent Address State | Text |
Enter the state of the applicant's permanent address.
|
| Zip Code | Text |
Enter the zip code of the applicant's permanent address.
|
| Personal Information | ||
| Name Last | Text |
Enter your last name as it appears on your identification documents.
|
| First | Text |
Enter your first name as it appears on your identification documents.
|
| undefined | Text |
Enter your middle name as it appears on your identification documents.
|
| App DOB MM | Text |
Enter the month of your date of birth (MM).
|
| App DOB DD | Text |
Enter the day of your date of birth (DD).
|
| App DOB YYYY | Text |
Enter the year of your date of birth (YYYY).
|
| Gender_M | CheckBox |
Check this box if your gender is male.
|
| Gender_F | CheckBox |
Check this box if your gender is female.
|
| Gender_X | CheckBox |
Check this box if your gender is non-binary or other.
|
| undefined | Text |
Enter the city and country where you were born.
|
| App SSN 1 | Text |
Enter the first three digits of your Social Security Number.
|
| App SSN 2 | Text |
Enter the next two digits of your Social Security Number.
|
| App SSN 3 | Text |
Enter the last four digits of your Social Security Number.
|
| App List all other name you have used | Text |
List all other names you have used.
|
| App List all other names you have used 2 | Text |
List any additional names you have used.
|
| Travel Information | ||
| undefined | Text |
Enter the date you plan to depart for your travel.
|
| undefined | Text |
Enter the date you plan to return from your travel.
|
| undefined | Text |
List the countries you plan to visit during your travel.
|