AUTHORIZED DIPLOMATIC OR OFFICIAL PASSPORT REQUEST TO Department Of

authorized diplomatic or official passport request to: department of state/special issuance agency 600 19th street, nw, suite 3.200 wash

AUTHORIZED DIPLOMATIC OR OFFICIAL PASSPORT REQUEST
TO: Department of State/Special Issuance Agency 600 19TH Street, NW,
Suite 3.200
Washington, DC 20006 (202) 485-8200
FROM: USAID/ 
Authorizing Official: 
1. EMPLOYEE’S NAME (Last, First, MI)
 
2. PASSPORT NO.
3. ISSUE DATE
4. EXPIRATION DATE
5. MAILING ADDRESS:
 
6. TELEPHONES
 
7. PLACE OF BIRTH
 
HOME PHONE
 
WORK PHONE
 
8. DATE OF BIRTH
(MM/DD/YYYY)  
9. POSITION TITLE
 
10. DIPLOMATIC TITLE
 
11. EFFECTIVE DATE
12. PERSONAL RANK DIRECT HIRE
FS   GS   AD  
12A. USPSC Contract Expiration Date  
OPIC IPA PASA RSSA TAACS
13. POST
USAID/ 
14. DEPARTURE DATE
 
15. TYPE OF PASSPORT REQUESTED
DIPLOMATIC OFFICIAL
16. SERVICE REQUIRED
Revalidation New Issue
17. ASSIGNMENT(One year or more)
 
18. TDY(Less than one Year)
 
19. COMPLETE WHEN DEPENDENTS ARE APPLYING FOR PASSPORTS
REVALIDATION
Dependent’s Name
Date of Birth
Place of Birth
Passport No.
Issue/Exp. Dates
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
20. REMARKS
 
21. EXTRA SERVICES REQUESTED: Expedited Service Larger, 48 page
passport
22. ATTENTION CLERK OF COURT/ACCEPTANCE FACILITY AGENT: Please accept
this authorization application for Official or Diplomatic passports
for the above USAID employees and listed dependents, in accordance
with Section 350 of the Clerk of Court Handbook. Please forward
applications, after proper execution, to: Special Issuance Agency, 600
19th Street, NW, Suite 3.200, Washington, DC 20006. A copy of this
letter MUST accompany each application in place of the regular
passport fee.
AUTHORIZED SIGNATURE OF TRAVEL & TRANSPORTATION DIVISION
CHIEF/TRANSPORTATION SPECIALIST
DATE
PRIVACY ACT STATEMENT
*
The information solicited on this form is authorized by, but not
limited to, those statutes codified in Titles 8, 18, and 22,
United States Code, and all predecessor statutes whether or not
codified, and all regulations issued pursuant to Executive Order
11295 of August 5, 1966. The primary purpose for soliciting the
information is to establish citizenship, identify, and entitlement
to issuance of a United States Passport or related facility, and
to properly administer and enforce the laws pertaining thereto.
*
The information is made available as a routine use on a
need-to-know basis to personnel of the Department of State and
other government agencies having statutory or other lawful
authority to maintain such information in the performance of their
official duties; pursuant to a subpoena or court order; and; as
set forth in Part 171, Title 22, Code of Federal Regulations (see
Federal Register, Volume 42, pages 49791 through 49795).
*
Failure to provide the information requested on this form may
result in the denial of a United States Passport, related
document, or service to the individual seeking such passport,
document, or service.
INSTRUCTIONS FOR COMPLETION OF AID FORM 5-255
Note: Leave “From block” and “block 22” blank, must be completed by
authorizing official
Please complete online or download and type, no handwritten form will
be accepted.
1) Enter name of sponsor (check "Dependents of" if applicable).
2) Leave blank
3) Leave blank
4) Leave blank
5) Employee in DC leave blank. Others; provide physical address and
phone for courier deliveries (only if someone will be present to
accept delivery). P.O. Box addresses will be delivered to via
registered mail. Personnel abroad enter Pouch Mail/Commercial Courier
addresses.
6) Self explanatory
7) Self explanatory
8) Enter Date of Birth, Month/Day/Year. (Acceptable = 31 JAN XX)
9) Enter Position Title (i.e. Foreign Service Officer, etc.).
10) Enter if applicable.
11) Leave blank
12) Direct Hire only. 12A) all others, as applicable.
13) Enter "W" for Washington or Post location.
14) Enter Departure Date.
15) Check type passport requested.
16) Check Service required.
17) Enter number of years of assignment.
18) Enter number of weeks or months.
19) Enter dependents' names, Date and Place of Birth. Leave other
blocks blank.
20) Enter supplemental data. (i.e. Birth Certificates, Marriage
Certificates, or any other relevant information submitted with
application).
21) Check Expedited when travel is imminent and visas are required,
check 48-Page when extensive travel is performed and extra pages are
needed to accommodate required visas.
22) Authorizing Official's (or Designee) signature and date.
EMPLOYEE’S CERTIFICATION:
I certify that I am a United States Government Direct hire / PSC
(circle one) employee and have an official need for the Diplomatic or
Official Passport(s) for which I am applying.
SIGNATURE:
DATE:
AID Form 5-255 (05/07) Page 2 of 2