|, U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS (5 corn Please Print Legib ESTIMATED BURDEN: 40 MIN Attention: Read WARNING on page 1 of instructions > Please select the document(s) for which you are applyii f KX] US. Passport Book —_—_L] US. Passport Card “Both [ The U.S. passport card is not valid for international aw travel For more: information see page 1 of instructions, ©) 28 Page Book (Standard) 0 52 Page Book (Non-Standard) Zz The 52 page: Page option = for those who frequently travel abroad during the passport validity period. and is recommended ApPACANIS WhO have prewcusly required the addition of viss pages ii |. Name Last pd [jo [| op potscode End. # Exp. EPSTEIN First JEFFREY EDWARD 2. Date of Birth (mm/ddiyyyy) Sex 4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.) 3. Mu F o1 20 1953 4 NEW YORK, NY 5. Social Security Number 6. Email Address (@.9., my_email@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.g., In Care Of - Jane Doe, Apt # 100) City State Zip Code Country, if outside the United States 00802 VI | 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 (mm/dd/yyyy) 11. 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 (mmidd/yyyy) Changed by Court Order ae. Please submit 8 certified copy (Photocopies are not accepted!) YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW | declare under penalty of perjury all of the following: 1) | am a citizen or non-citizen national of the United States and have not, since acquiring U. tenders hose any of the acts listed under “Acts or Conditions” 27 98g ow ofthe scons of is pcan (ness explanatory satan saad), 2) the statements made Teen ae Ea re ae mel moan and mph pope ale eee daa ey toda bop oT aio en Submitted with this application is a genuine, current photograph of Sac & Inova weed aha Uabesaies Ws Ween Da cae the application form. Matin ihe Bete enh 7 Applicant's Legal Signature = |- FOR ISSUING OFFICE ONLY C1] perekcr [] pprexsim | | pprcocR[] pprcosR () Marnage Certificate Date of Mariage/Place Issued: UL) Court Order Date Filed/Court * DS 82 B 08 2013 1 * DS-82 08-2013 Page 1 of 2 EFTA00314145