EFTA00314138.pdf

OMR CONTROL NO 1406.0020 U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS OMB EXPiRATiON DATE 193177'. Pease Print Legibly Using Black Ink Only PSIS/ATM BURDEN 40 MIN Attention' Read WARNING on page 1 of instructions Please select the document(s) for which you are applyi : r IS1 U.S. Passport Book O U.S. Passport Card LI Both The U S passport cad is mg void for ntornakoal ail Irani For nye 'tension sea Dope 1 of novo= 0 28 Page Book (Standard) 0 52 Page Book (Non-Standard) ikn_e: Trio $2 Me Orton is for nose wroseguintlytoreel xnal nano ma pare. ninny airlock and oreccernended ic,gieseis woo have genoanimewed Ttacksbon q viii pt Oi 1. Name Last 1-10 non DP DOTS Cod* EPSTEIN End. s Exp. First Middle JEFFREY EDWARD 2. Date of Birth (inrri/ddyyyy) 3. Sex 4. Place of Birth (City & Slate if in the U.S.. or City 6 Country as it is presently known.) F 01 20 1953 X NEW YORK, NY 5. Social Security Number 6. Email Address (e.g . my_emaikdOMmn com) 7. Primary Contact Phone Number 090 44 3348 JEEVACATION@GMAIL . COM 8. Mailing Address: Line 1 Street/RFDS, P.O. Box. or URB. 6100 RED HOOK QUARTER, B3 Address Line 2: Cleary label Apartment, Company, Suite. Unit. Building, Floor, In Care Of or Attention if applicable. (e.g., In Care Of-Jane Doe. Apt * 100) City State Zip Code Country, d outside the United States ST THOMAS VI 00802 9. List all other names you have used. (E complus Bulb Name Madon. Previous Marriage. Legal Name Change. Attach additional pages if needed) A B. 10. Passport Book and/or Passport Card Information Your name as printed on your most recent U.S. passport book and/or passport card JEFFREY EDWARD EPSTEIN Most recent passport book number Issue dale (ramtddanyy) 516923892 06/30/2014 Most recent passport card number Issue date (nerliddYYTO 11. Name Change Information Complete einemo is afferent than last U.S. passport book or passport card Changed by Mwriage Place of Name Change (City/State) Date (mtn/ddyyyy) Changed try Court Order Please submit a centlea copy. (Photocopies are not accepted?) CONTINUE TO PAGE 2 YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW I declare under penalty of penny all of the following 1) I am a °Wen or non-Owen nasonal of the United States and have nOt since aniuinngUS ottzenship or nabonalrty performed any of the ads listed under "Ads or Condetone on page lour of the instructions of pus application (unless explanatory statement is attached). 2) the statements made on the appication are true and correct 3) I have not knonsigly and wilfully made raise statements or included false documents in support of INS application. a) the phonograph suet wei this application is a genuine. current photograph of me. and 5) I have read and understood the warning on pogo one of trio instructor* to the applicator form. Appheant's Legal Signature FOR ISSUING OFFICE ONLY PPT DK Ca 1 I PPT BK SA1 [1 PPTCDCI U PPT CD UR E Marriage Cortical° Date of Manage Platt Issued U Court order Date t ileOrCoun p rein To 11 Omer. Iii!!!!!!!!!!!. Mathes Fa Issuing Ogee Only —IF Bk Fee Ca Fee tl- Postage Other DS-82 08.2013 Paao1 of 2 EFTA00314138