% a, U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS 98 connote toa 208e Please Print Legibly Using Black Ink Only ESTIMATED BURDEN: 40MIN Attention: Read WARNING on page 1 of instructions Please select the document(s) for which you are applyi KK] U.S. Passport Book [1] US. Passport Card Both The U.S. passport card is not valid for international air travel. For more information see page t of instructions. Gi) 28 Page Book (Standard) C52 Page Book (Non-Standard) | gp Behe geld he api pod tephra ete een hae Jeger and ts recommended | BOPECENIS whd have previously required Ne sddibon of visa 4. Name Last | | EPSTEIN First Middle JEFFREY EDWARD 2. Date of Birth (mm/dd/yyyy) Sex 4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.) 3. u F. o1 20 1953 xX NEW YORK, NY 5. Social Security Number 6. Email Address (¢.g., my_emaii@domain.com) 7. Primary Contact Phone Number 090 44 3348 JEEVACATION@GMAIL.COM 8. Mailing Address: Line 1: Street/RFD#, 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.9., In Care Of - Jane Doe, Apt # 100) \ [lo End. # City State Zip Code Country, if outside the United States ST THOMAS vI 00802 9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed) A B. 10. Passport Book and/or Passport Card Information Your name gs 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 (mm/dd/yyyy) | 44. Name Change Information Complete if name is different than last U.S. passport book or passport card Changed by Marriage Place of Name Change (City/State) Date (mm/dd/yyyy) attag Changed by Court Order Bie PSP uo” | Please submit a certified copy. (Photocopies are not accepted!) YOU MUST SIGN AND DATE THE AEPLICATION IN THE DESIGNATED AREA BELOW | dectare under penalty of pequry all of the following: 1) 1am 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 Conditons” 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) | have not knowingly and wilfully made talse statements or included false documents im support of this application; 4) the photograph submitted with this application is a genuine. current photograph of me: and 5) | have read and understood the warning on page one of the instructions to the application form, x Applicants Legal Signature FOR ISSUING OFFICE ONLY [| pptakor [| pprakse [| pprcocer || PPT CD SIR () Marriage Certificate Date of Marriage/Place Issued (L) Court Order Date Filea/Court * DS 82 B 08 2013 1 * DS-82 08-2013 Paao 1 of 2 EFTA00314138