801 228
th
Ave SE
Sammamish, WA 98075
425-295-0500 | www.sammamish.us
2022-01-PAC Page 1 of 5
PASSPORT APPOINTMENT
CHECKLIST
ABOUT THE PASSPORT APPOINTMENT CHECKLIST
Instructions
Complete, print, and bring
this form to your passport
appointment along with all of
the required items.
Resources
U.S. Department of State
Passport Website
City of Sammamish
Appointment Reservations
Questions?
Passports@sammamish.us
425-295-0500
City of Sammamish
801 228th Ave SE
Sammamish, WA 98075
www.sammamish.us
This Checklist is designed to help you identify which items are required for
your passport acceptance appointment.
This
form must be completed, printed, and brought to your passport
appointment along with the required items. Any missing items will require
you to reschedule your appointment for a later date.
SPECIAL INFORMATION FOR CHILDREN UNDER AGE 16
Dif
ferent items are needed if your appointment is for a child under age 16.
Please see pages 4-5 for more details.
Pl
ease note that both parents or the child’s legal guardian(s) must
accompany the child(ren) to the appointment.
FEES
Passport appointments require two separate payments: one to the U.S.
Department of State and the other to the City of Sammamish. The costs
below are per application.
PASSPORT FEES
Fees vary by age of the applicant & options selected.
Each application must be paid for separately. For example,
two applications will require two separate checks.
Personal or cashier’s checks or money orders are the only
accepted form of payment & must be made payable to the
U.S. Department of State.
Please see travel.state.gov for current fees.
EXECUTION (ACCEPTANCE) FEE
Application Processing Fee (per application), $35
Cash, Visa/Mastercard, check, or money order is accepted &
must be made payable to the City of Sammamish.
2022-01-PAC Page 2 of 5
PASSPORT APPOINTMENT CHECKLIST
SUBMITTAL CHECKLIST – APPLICANTS AGES 16 YEARS OR OLDER
The below items are required for each applicant, ages 16 years or older. You must bring each of numbered
items below with you to your appointment.
Any missing items will require you to reschedule your appointment for a later date.
☐
01. Completed Passport Appointment Checklist (you may skip pages 4-5)
☐
02. Completed Form DS-11
− Use the State Department’s Form Filler to complete & print the form online or download, print
& complete the pdf using black ink only.
− If you make an error, complete a new form – do not correct the mistake
☐
03. Proof of U.S. Citizenship (original or certified copy) through one of the below:
☐
U.S. birth certificate that meets all of the below requirements:
− Issued by the City, County, or State of birth
− Lists your full name, date of birth, and place of birth
− Lists your parent(s)’ full names
− Has the date filed with the registrar’s office (must be within one year of birth)
− Has the registrar’s signature and the seal of the issuing authority
☐
Fully valid, undamaged U.S. passport (may be expired)
☐
Consular Report of Birth Abroad or Certification of Birth
☐
Certificate of Naturalization or Citizenship
☐
04. Photocopy of Proof of U.S. Citizenship
− One photocopy of the front & back (if it has printed information)
☐
05. Proof of Identity (original) through one of the below that includes a photo that is a good likeness:
☐
Previous or current U.S. passport book or card
☐
Driver’s License (Temporary License or Learner’s Permit are not accepted)
☐
Military identification
☐
Federal, State, or City government employee identification
☐
Certificate of Naturalization or Citizenship
☐
06. Photocopy of Proof of Identity
− One photocopy of the front and the back
Submittal Checklist for Applicants Ages 16 Years or Older continued on next page
2022-01-PAC Page 3 of 5
PASSPORT APPOINTMENT CHECKLIST
SUBMITTAL CHECKLIST – APPLICANTS AGES 16 YEARS OR OLDER (CONTINUED)
☐
07. One Color Photograph, 2 x 2 inches in size that meets the below requirements:
− Head must be 1-1 3/8 inches from the bottom of the chin to the top of the head
− Taken less than six months ago
− No glasses or hat/head covering*
− Has a plain white or off-white background
− Head must face the camera directly with full face in view
− Printed on matte or glossy photo quality paper
*Some exceptions apply. Please see Form DS-11 for more details.
☐
08. Payment to the U.S. Department of State for the applicable fees
− See page 1 of this Checklist and travel.state.gov for more details
− Money Order, Cashier’s Check or Personal check are the only accepted form of payment
− It is recommended that applicants bring their checkbook with them so that errors can be fixed
immediately, and the appointment doesn’t have to be rescheduled
☐
09. Payment to the City of Sammamish for the execution fee
− See page 1 of this Checklist for more details
2022-01-PAC Page 4 of 5
PASSPORT APPOINTMENT CHECKLIST
SUBMITTAL CHECKLIST - APPLICANTS 15 YEARS OR YOUNGER
The below items are required for each applicant, ages 15 years or younger. You must bring each of numbered
items below with you to your appointment.
Any missing items will require you to reschedule your appointment for a later date.
☐
01. Completed Passport Appointment Checklist (you may skip pages 2-3)
☐
02. Completed Form DS-11
− Use the State Department’s Form Filler to complete & print the form online or download, print
& complete the pdf using black ink only.
− If you make an error, complete a new form – do not correct the mistake
☐
03. Evidence of the child’s U.S. citizenship through one of the below:
☐
U.S. birth certificate that meets all of the below requirements:
− Issued by the City, County, or State of birth
− Lists child’s full name, date of birth, and place of birth
− Lists parent(s)’ full names
− Has the date filed with the registrar’s office (must be within one year of birth)
− Has the registrar’s signature and the seal of the issuing authority
☐
Fully valid, undamaged U.S. passport (may be expired)
☐
Consular Report of Birth Abroad or Certification of Birth
☐
Certificate of Naturalization or Citizenship
☐
04. Evidence of the child’s relationship to parents/guardian(s) (original) through one of the below:
☐
Birth certificate with the names of the parent(s)/guardian(s) and child
☐
Consular Report of Birth Abroad with the names of the parent(s)/guardian(s) and child
☐
Parental/guardian government-issued identification (original)
☐
05. Parental/guardian government-issued identification (photocopy of front and back)
☐
06. One Color Photograph, 2 x 2 inches in size that meets the below requirements:
− Head must be 1-1 3/8 inches from the bottom of the chin to the top of the head
− Taken less than six months ago
− No glasses or hat/head covering*
− Has a plain white or off-white background
− Head must face the camera directly with full face in view
− Printed on matte or glossy photo quality paper
*Some exceptions apply. Please see Form DS-11 for more details.
Submittal Checklist for Applicants Ages 15 Years or Younger continued on next page
2022-01-PAC Page 5 of 5
PASSPORT APPOINTMENT CHECKLIST
SUBMITTAL CHECKLIST - APPLICANTS 15 YEARS OR YOUNGER (CONTINUED)
☐
07. Payment to the U.S. Department of State for the applicable fees
− See page 1 of this Checklist and travel.state.gov for more details
− Money Order, Cashier’s Check or Personal check are the only accepted form of payment
− It is recommended that applicants bring their checkbook with them so that errors can be fixed
immediately, and the appointment doesn’t have to be rescheduled
☐
08. Payment to the City of Sammamish for the execution fee
− See page 1 of this Checklist for more details
PARENT/GUARDIAN REQUIRED ATTENDANCE & DOCUMENTATION
Both parents or the child’s legal guardian(s) must accompany their child(ren) to the appointment. If only
one parent/guardian can appear, one of the below is required:
☐
The second parent’s notarized written statement consenting to the passport issuance for the child.
− Must be signed and notarized on the same day
− Must be accompanied by a photocopy of the front and back of the second parent’s government-
issued photo identification
− Must be less than three month’s old and include the child’s full name & date of birth
☐
Form DS-3053 (including the child’s full name and date of birth)
☐
The second parent’s death certification (if applicable)
☐
Evidence of sole authority to apply (i.e., a court order granting sole custody or a birth certificate listing
only one parent)
☐
A written statement (made under penalty of perjury) explaining, in detail, why the second parent
cannot be reached
☐
Form DS-5525
