EFTA00314145.pdf

U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS c""°""m°1-N° 14136C2D OMB EXPIRATION OA1L 12d1-2Ulb Please Print Legibly Using Slack Ink Only ESTIMATED BURDEN 40 MIN Attention Read WARNING on page I of instructions Please select the document(s) for which you are applyiN: (20 U.S. Passport Book ThaUS perspen card is a El U.S. Passport Card Both LJ vaid for ranmanonal Pr ISM. Pa more remnant See race 1 of emir:tem I23 28 Page Book (Standard) CI 52 Page Book (Non-Standard) me to tope 00tan a for these *no 00Chertly Vend abroadrising TS passport radix. penod. are *r€00mrsredeC •rs. ape meta dro lova preenudy Tortured the eaddion of ma peps 1. Name Last I D . I DP DOTS Code EPSTEIN End. A Exp. First Middle JEFFREY EDWARD 2. Date of Birth (rrunickVyyyy) 3. Sox 4. Place of Birth (City & Suite Ain the U.S, or City Li Country as it is presently known.) F 01 20 1953 X NEW YORK, NY 5. Social Security Number 6. Email Address (0. g . my emaiifildomain.00m) 7. Primary Contact Phone Number 090 44 3348 [email protected] 8. Mailing Address: Line 1: Street/RFDtt, P.O. Box. or URB. 6100 RED HOOK QUARTER, B3 Address Line 2: Clearly 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. if outside the United States ST THOMAS VI 00802 9. List all other names you have used. (Examples: Binh Name. Maiden, Previous Marriage. Legal Name Change Attach additional pages rf needed) 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 date (MM/dd/yyyy) 516923892 06/30/2014 Most recent passport card number Issue date (mmiddiyyyy) 11. Name Change Information Complete if name is different than last U.S. passport book or passport card Changed by Marnage Place of Name Change (City/State) Date (mmfackyyyy) Changed by Court Order Please Submit a (erotica cep', (Photocopies ere not accepts-ea CONTINUE TO PAGE 2 YOU MUST SIGN AND DATE THE APPLICATION THE DESIGNATED AREA BELOW I declare under penalty of peel-ay an of the followng: 1) I are a Citizen or non wren natonal ofIN the United States and halve not since *equaled U $ Onronshrp or natiOnality performed any of the acts listed under 'Acts or Crendibons- on page four of the ant/Ireton, of Mc appeal:cc (unless explanatory statement is attached), 2) the statements made on the application are true and correct: 3) I have not knowisgty and wilfully made false statements or included false documents in support 01 submitted with this applicaton is a genuine. current photograph 01 me: and a) 1 have read thiS arrolestion: 4) the photograph and understood the warning on page one of the rnStructiOns to the appecatIon toms x Sepicanr La,___Sionals.• FOR ISSUING OFFICE ONLY PPT BK CFR n PPT Eta SM I I PPT CO Cat n PPT CD SR Marriage Certificate Date of Marriage/Place Issued- I 1 Court Order Date Fled/Court- From To n Other f Attached: For Issuing Office Only e•••elk Bk Foe Cd Fee EF PoStarte Other * DS 82 ft 08 2013 I • D5-82 08-2013 Pao* 1 of EFTA00314145