U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS c.l ac

U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS c.l ac ONHc),(1.1,r-TioN"°0,:ffFs'„-„, a., Please Print Legibly Using Black Ink Only CSTIMAIFO htPIDEN 40 MIN Attention Read WARNING on page 1 of instrucbons Please select the document(s) for which you are applying: U.S. Passport Book 0 U.S. Passport Card 0 Both The U 5 prnSCOn owe 6 R71 valid for iniunibthel at tram) for more rformabOn See POPO 1 d ralhtbOnS 0 25 Page Book (Standard) I1 52 Page Book (NonStandard) Note) TN:52 page OCIOn et tot rtne !en frechiPhIly raver aerpiel axing the pampa v014dy pen* 3114 feCOM1104044 rya npvnarne who have pronoun" rorprnrd ti WOW) °Into P.)155 1. Name Last EPSTEIN First JEFFREY 2. Date of Birth (nunaktlYYYY) 01 20 1953 5. Social Security Number Middle EDWARD no Clo OOP DOTS Code Cott Exp. 3. Sex 4. Place of Birth (City & Slate if in the U.S., or City & Country as it is presently known ) M F X NEW YORK, NY S. Email Address (o 0. my_omededomein com) 7. Primary Contact Phone Number 090 44 3348 JEEVACATION@OMAIL . COM 8. Mailing Address: Line 17 Street/RFD#. P.O. Box. or URB. 6100 RED HOOK QUARTER, B3 Address Line 2: Clearty label Apartment. Company. Suite. Unit. Budding, Floor, In Care Of or Attention if applicable. (e g. In Care Of - Jane Doe. Apt # too) City State Zip Code Country. if outside the Unted States ST THOMAS VI 00802 9. List all other names you have used. (Examples Birth Name, Maiden, Previous Marriage. Legal Name Change. Attach addrbonal pages of needed) A. 8 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 EPSTEIN Most recent passport book number Issue date (nmAidNyyy) 516923892 06/30/2014 Most recent passport card number Issue date (enrevdcONYY) 11. Name Change Information Complete if name is different than last U.S. passport book or passport card obbbgeb ty Kumar Place of Name Change (Ciiy/State) Date (mnilddryyyy) Changed by Court Order Pleat& submit a oeflthaa cap. nLI totocoplaa are not accepted!) CONTINUE TO PAGE 2 ► YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW I 4CC.310 under penally of pottery all of ere following I) I am a olden or non-otrzen rational of the united States and nave not. since asouirng U.S. eltiZen5hp or nationality. performed any Or the acts sod ulder Conditions" on page "out of the ins:Ivaco* of tins appication (unless explanatory statement is attartre). 2) the tratemenin mad! on the app cation ore true and correct 3) I have not knowing/{ and willfully made false statements of induCted false documents in support Of MIS apptiCabOh. a) the photograph solo-rutted with tnis apptication os a genuine, current photograph of me. and 5) I rave read and underStood the warning on page one of the instructions to the a ppecahon form x ApplicairsIltgalSylatips L FOR ISSUING OFFICE ONLY i PPr BK [1 Pintocsm I I Fr mem❑ pprcosmi _I Marriage Carina Date of Marriage/Place Issued. I I Cowl Order Date Filed/Court' From To nom. LI Anadvtd. For Issuing Office Only Bk Fee Cd Fee EF Postage Other DS 82 808 2013 1* DS-92 08.2013 Pal/0102 EFTA00314126