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ACTS OR CONDITIONS
(If any of the below-mentioned acts or conditions have been performed by or apply
to the applicant, the portion which applies should be lined out, and a
supplementary explanatory statement under oath (or affirmation) by the applicant
should be attached and made a part of this application.)
I have not, since acquiring United States citizenship/nationality, been naturalized
as a citizen of a foreign state; taken an oath or made an affirmation or other
formal declaration of allegiance to a foreign state; entered or served in the armed
forces of a foreign state; accepted or performed the duties of any office, post, or
employment under the government of a foreign state or political subdivision
thereof; made a formal renunciation of nationality either in the United States, or
before a diplomatic or consular officer of the United States in a foreign state; or
been convicted by a court or court martial of competent jurisdiction of committing
any act of treason against, or attempting by force to overthrow, or bearing arms
against the United States, or conspiring to overthrow, put down, or to destroy by
force, the government of the United States.
Furthermore, I have not been convicted of a federal or state drug offense or
convicted of a "sex tourism" crime, and I am not the subject of an outstanding
federal, state, or local warrant of arrest for a felony; a criminal court order
forbidding my departure from the United States; or a subpoena received from the
United States in a matter involving federal prosecution for, or grand jury
investigation of, a felony.
PRIVACY ACT STATEMENT
AUTHORITIES: Collection of this information is authorized by 22 U.S.C. 211a et
seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E, 22 U.S.C. 2714a(f), Section 236 of the
Admiral James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal
Years 2000 and 2001; Executive Order 11295 (August 5, 1966); and 22 C.F.R. parts 50
and 51.
PURPOSE: We are requesting this information in order to determine your eligibility
to be issued a U.S. passport. Your Social Security number is used to verify your
identity.
ROUTINE USES: Your Social Security number will be provided to the Department of the
Treasury and may be used in connection with debt collection, among other purposes
authorized and generally described in this section. This information may be
disclosed to another domestic government agency, a private contractor, a foreign
government agency, or to a private person or private employer in accordance with
certain approved routine uses. These routine uses include, but are not limited to,
law enforcement activities, employment verification, fraud prevention, border
security, counterterrorism, litigation activities, and activities that meet the
Secretary of State's responsibility to protect U.S. citizens and non-citizen
nationals abroad. More information on the Routine Uses for the system can be found
in System of Records Notices State-05, Overseas Citizen Services Records and State-
26, Passport Records.
DISCLOSURE: Providing information on this form is voluntary. Be advised, however,
that failure to provide the information requested on this form may cause delays in
processing your U.S. passport application and/or could also result in the refusal
or denial of your application.
Failure to provide your Social Security number may result in the denial of your
application (consistent with 22 U.S.C. 2714a(f)) and may subject you to penalty
enforced by the Internal Revenue Service, as described in the Federal Tax Law
section of the instructions to this form.
ELECTRONIC PASSPORT STATEMENT
The U.S. Department of State now issues a type of passport book containing an
embedded electronic chip called an "Electronic Passport". The electronic passport
book continues to be proof of the bearer's United States citizenship/nationality
and identity, and looks and functions in the same way as a passport without a chip.
The addition of an electronic chip in the back cover enables the passport book to
carry a duplicate electronic copy of all information from the data page. The
electronic passport book is usable at all ports-of-entry, including those that do
not yet have electronic chip readers.
Use of the electronic format provides the traveler the additional security
protections inherent in chip technology. Moreover, when used at ports-of-entry
equipped with electronic chip readers, the electronic passport book provides for
faster clearance through some of the port-of-entry processes.
The electronic passport book does not require special handling or treatment, but
like previous versions should be protected from extreme heat, bending, and from
immersion in water. The electronic chip must be read using specially formatted
readers, which protects the data on the chip from unauthorized reading.
The cover of the electronic passport book is printed with a special symbol
representing the embedded chip. The symbol will appear in port-of-entry areas
where the electronic passport book can be read.
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average
40 minutes per response, including the time required for searching existing data
sources, gathering the necessary data, providing the information and/or
documentation required, and reviewing the final collection. You do not have to
supply this information unless this collection displays a currently valid OMB
control number. If you have comments on the accuracy of this burden estimate and/or
recommendations for reducing it, please send them to: Passport Forms Officer, U.S.
Department of State, CA/PPT/S/L, 44132 Mercure Cir, P.O. Box 1227 Sterling,
Virginia 20166-1227.
DS-82 01-2017
Instruction Page 4 of 4
U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS OMB CONTROL NO. 1405-
0020
OMB EXPIRATION DATE: 09-30-2019
Attention: Read WARNING on page 1 of instructions
Please select the document(s) for which you are applying:
U.S. Passport Book U.S. Passport Card X Both
The U.S. passport card is not valid for international air travel. For more
information see page 1 of instructions.
Regular Book (Standard) X Large Book (Non-Standard)
Note: The large book option is for those who frequently travel abroad during the
passport validity period, and is recommended for applicants who have previously
required the addition of visa pages.
D O DP DOTS Code End. # Exp.
ELIAS PINA, DOMINICAN REPUBLIC
1. Name Last LIMARDO MR
First
ADALBERTO
2. Date of Birth (mm/dd/yyyy)
Middle
4. Place of Birth (City & State if in the U.S., or City & Country as it is
presently known.) 6. Email (Info alerts offered at travel.state.gov) 7. Primary
Contact Phone Number
--
01 07 1964
5. Social Security Number
8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.
3. Sex MF
X
--
[email protected] 829-638-3838 MANZANA C#8, URB CARMEN MARIA II
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
SANTO DOMINGO 10510
9. List all other names you have used. (Examples: Birth Name, Maiden, Previous
Marriage, Legal Name Change. Attach additional pages if needed) A. ADALBERTO EMILIO
LIMARDO FELIZ B.
099 78 7010
DOMINICAN REPUBLIC
Attach a color photograph taken within the last six months
10. Passport Book and/or Passport Card Information
Your name as printed on your most recent U.S. passport book and/or passport card
ADALBERTO LIMARDO
Most recent passport book number
478892559
Most recent passport card number
Issue date (mm/dd/yyyy)
03/08/2011
Issue date (mm/dd/yyyy)
11. Name Change Information Complete if name is different than last U.S.
passport book or passport card
Changed by Marriage Changed by Court Order
Place of Name Change (City/State) Date (mm/dd/yyyy) Please submit a certified 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 perjury all of the following: 1) I am a citizen or non-
citizen national of the United States and have not, since acquiring U.S.
citizenship or nationality, performed any of the acts listed under "Acts or
Conditions" on page four of the instructions of this application (unless
explanatory statement is attached); 2) the statements made on the application are
true and correct; 3) I have not knowingly and willfully made false statements or
included false documents in support of this application; 4) the photograph
submitted with this application is a genuine, current photograph of me; and 5) I
have read and understood the warning on page one of the instructions to the
application form.
x
Applicant's Legal Signature
Date
FOR ISSUING OFFICE ONLY PPT BK C/R PPT BK S/R PPT CD C/R PPT CD S/R
Marriage Certificate
Court Order
From To:
Other: Attached:
Date of Marriage/Place Issued: Date Filed/Court:
* DS 82 B 08 2013 1 *
For Issuing Office Only Bk Fee Cd Fee EF Postage Other
Please Print Legibly Using Black Ink Only ESTIMATED BURDEN: 40 MIN
DS-82 01-2017
Page 1 of 2
STAPLE 2" x 2" STAPLE
STAPLE 2" x 2" STAPLE
Name of Applicant (Last, First & Middle) Date of Birth (mm/dd/yyyy) LIMARDO MR,
ADALBERTO 01/07/1964
12. Height
GRAY
14. Eye Color
BROWN
AIRPLANE MECHANIC
17. Additional Contact Phone Numbers
X Home Cell Home Cell 809-922-8475 Work 809-549-0475 X Work
16. Employer or School (if applicable) AMERICAN AIRLINE
5ft. 11in.
13. Hair Color
15. Occupation
18. Permanent Address: If P.O. Box is listed under Mailing Address or if
residence is different from Mailing Address.
Street/RFD # or URB (No P.O. Box)
78 SASSAFRAS ST
City
PATERSON
Apartment/Unit
State Zip Code
NJ 07524
19. Emergency Contact - Provide the information of a person not traveling
with you to be contacted in the event of an emergency.
Name
JOSE LIMARDO
City State
NJ
PATERSON
Address: Street/RFD # or P.O. Box
78 SASSAFRAS ST
Zip Code
Phone Number
Relationship
Apartment/Unit
07524
862-271-3430
SON
20. Travel Plans
Departure Date (mm/dd/yyyy) Countries to be visited
Return Date (mm/dd/yyyy)
STOP! YOU HAVE COMPLETED YOUR APPLICATION BE SURE TO SIGN AND DATE PAGE ONE
WHERE DO I MAIL THIS APPLICATION?
FOR ROUTINE SERVICE (If you live in CA, FL, IL, MN, NY, or TX):
National Passport Processing Center P.O. Box 640155
If applying in the United States or Canada: FOR ROUTINE SERVICE (If you live in
any other state or Canada):
National Passport Processing Center P.O. Box 90155
Philadelphia, PA 19190-0155
FOR EXPEDITED SERVICE (Additional Fee, any state or Canada):
National Passport Processing Center
P.O. Box 90955
Philadelphia, PA 19190-0955
Because of the sensitivity of the enclosed documents, Passport Services recommends
using trackable mailing service when submitting your application.
Irving, TX 75064-0155
If applying outside the United States or Canada:
United States citizens residing outside the U.S. or Canada CANNOT submit this form
to domestic addresses listed above. Such applicants should visit
www.usembassy.gov to find the nearest U.S. Embassy or Consulate for procedures for
applying outside the United States.
* DS 82 AB 08 2013 2 *
DS-82 01-2017 Page 2 of 2