saturday i cleaned for about 3 hours.

slept at 4 am

made expense notes for car.

june expenses:

car:

electric $1100

misc

other

autopay: car ins $60.

modem tax 23

what else? paid $1000 on 5th 3rd card. so cash basis, car 2000, electric 1100, credit card $1000, misc 300? running total $4400. however, that's not typical month. income: oil $50, plasma $150, not much else? so $200.

car expenses

purchase $1400.

other:

plates and title $200

power steering fluid, blinker fluid $7

oil change $21

running total: 228 + 1400 = 1628

gas

$36.22 foulk rd 6/16

$41 wash pa 6/17 3.21/gln 77

$34 spiceland in 6/17 111

$18 indy 6/22 130

today is 6/26.

running total 130

need logbook and to write down miles. trip indicator:

did

1 trash 2 po box 3 gym 4 plasma $50 5 spray for bugs 6 laewn mower 7 laundry 7.5 emailed tommy 0 jalr.

hardware store was closed, 6 pm, now 8. i should cover the mower, raining. saw dawn. not professionally.

to do

1 make better list. 2 gas for mower. 3 mice. 4 bugs. 5 clean car. 6 put away laundry. 7 fix reddit chat problem. 8 x mke comic on other computer. 9 x chop down bush at driveway for better visibility. 10 x inspect yard for trash, scrap.

11. x outline brief

friday list:

1 hr cleaning. filed utility commission dispute. x next: mice. x aes building on circle. x utility regulatory commission 101 W Washington St #1500e, Indianapolis, IN 46204 did list got power turned back on. did laundry applied at hooters to do: update resume for castleton hooters manager job. bought moosetraps emailed tommy applied at hooters

billing note: just found out about a rhode island disclaimer case, first circuit just heard oral arguments.

it's by the people who brought janus. maybe i can work with them.

12:30 pm for the next hour or so, will update. 2:48 so 2 hours and counting. mailed hasen, contacted plaintiff's firm. 4:20 finished listening to oral argument. so nearly 4 hours. 4:28 taking a break to do other things for a short bit, will return here. oh abut to email the lawyer so that's still billable time. sent email, 4:45 so 4.25 hours (4 1/4). break time to move the fan upstairs. resume 7:32. pm 6/15/21 (same day)

group https://libertyjusticecenter.org/about/

complaint https://ljc-assets.s3.amazonaws.com/2019/11/LJC-Complaint-Filed-11-21-19-00043363xC230D.pdf dsuhr@libertyjusticecenter.org bkelsey@libertyjusticecenter.org daniel suhr. note: complaint looks fine.

oral argument

possible to do item letter brief mentioning controlling cases, persuasive cases, make argument that state interst is lessened by being prohibited by state constitution.

erroneous decision below https://ljc-assets.s3.amazonaws.com/2019/11/Gaspee-v.-Mederos-Memorandum-and-Order.pdf

list of errors in decision below

1. "whether those burdens are substantially related to achieving that end." improper legal standard. strict scrutiny is required.

2. "A facial challenge is not limited to a plaintiff’s particular case and can only succeed where the plaintiff establishes “that no set of circumstances exists under which the Act would be valid.” John Doe No. 1 v. Reed, 561 U.S. 186, 194 (2010); United States v. Salerno," wrong to apply salerno to first amendment case. also not clear that plaintiffs didnt raise an as applied challenge.

3. improper reliance on citizens united. however, court cites nom v mckee, previous precedent, so need to distinguish. NOM, i think, was a corporation? and plaintiffs are not. ok, best argument becerra and janus overule NOM.

4. buckley v valeo is not a disclaimer case.

(i am skipping a bunch of stuff about NOm v mckee)

5. "mcintyre acted alone."

6. little old lady exception misinterprets mcintyre and fails to grok talley.

3. again misinterprets citizens united. oh wait, is this a 501c3? ok plaintiffs are two 501c4s. that's a major weakness of their case. should have had an individual plaintiff. so they do need an facial challenge to the disclaimer statute.

Blakeslee v. St. Sauveur, 51 F. Supp. 3d 210 (D.R.I. 2014) note to self look up this case, seems to be a rhode island disclaimer case.

7. But more importantly, it is undisputed that the plaintiffs levy a facial challenge to the Act. ... seems as applied and facial.

8. ok finally we get to becerra....

the court's argument is the rhode island disclaimer regs are content neutral, and cites several local cases. not sure how i feel about that. mentions wooley but does not apply it.

https://www.jdsupra.com/legalnews/duo-of-federal-court-rulings-deal-blow-14251/ one about disclosure in new york, 2019. one from new jersey.

https://libertyjusticecenter.org/media/boston-globe-sides-first-amendment-battle-rhode-island-donor-disclosure-law/

looking now at campaign legal center lwv amicus.

Other circuits likewise have recognized that exacting scrutiny applies to all aspects of a state’s disclosure framework. See Nat’l Ass’n for Gun Rights, Inc. v. Mangan, 933 F.3d 1102, 1120 (9th Cir. 2019) (collecting cases), cert. denied, 140 S. Ct. 2825 (2020). mangan was a disclosure case, not a disclaimer case. discussd a few cases, would not say it collected them. mangan found one montana disclosure statute unconstitutional under lax scrutiny, upheld others. 1145 pm to 12:15 am 6/16/21. This Circuit’s decisions confirm th

https://campaignlegal.org/document/gaspee-project-v-mederos-united-states-appellate-court-first-circuit-amicus-curiae-brief

https://dockets.justia.com/docket/circuit-courts/ca1/20-1944

http://media.ca1.uscourts.gov/files/audio/20-1944.mp3 oral argument. some main themes: does citizens united control? does nom I and II control? "mcintyre was an individual" is mcintyre still good law? becerra and janus. i've been mispronouncing becerra. to do: email lawyer. robbin stewart 4:43 PM (5 minutes ago) to dsuhr, me Hello. Robbin Stewart here. This morning I saw an article in ballotpedia's newsletter about your case. That was the first I've heard of it. I am a semiretired Indianapolis attorney with a bit of a fixation on these disclaimer cases. I was the plaintiff in stewart v taylor (s d ind 1997) which found indiana's disclaimer statute unconstitutional per mcintyre. I was then lead counsel in majors v abell, where we lost on the same issue at the 7th circuit, and also anonymous v delaware, dismissed on standing grounds. I have a specific question and more general one. Given that oral argument has already happened, would it be too late to file an amicus in support of your position, perhaps a letter brief? I know the merits of your dispute quite well, but I've never been great at procedure. Next, hey, great work. The liberty justice center seems like an interesting organization. I am looking for local counsel, and cocounsel, for a challenge to delaware's disclaimer statute, which is pretty similar to the one at issue in your case. At some point I would like to do a new challenge to Indiana's statute, in light of becerra and janus. Feel free to forward this to others in your organization. If I had cocounsel, I would like to go state by state challenging these disclaimer rules. I am less interested in the other half of your case, about disclosure. Generally disclosure statutes get upheld per Valeo, although specific aspects can be challenged as unduly burdensome. Perhaps your organization and I can work together on these type of cases. Best way to reach me is this email, although my phone at the moment is 302 529 1529. Sincerely, Robbin Stewart. === roughest outline of comments to the first circuit. Summary of argument: Citizens United was dicta, and is not controlling. McIntyre is controlling, and governs this case, along with Janus, Becerra, Barnette, Talley, Riley v Federation, Tornillo, Wooley, Buckley v ACLF, Watchtower. argument Town of Vincent v Reed overruled the idea expressed in NOM that political signs get less than strict scrutiny. The proper standard is strict scrutiny, which Justice Scalia in McIntyre called a kiss of death standard. This panel should recognize that NOM is no longer either controlling or persuasive. Plaintiffs, both corporations, have the right to assert the 3rd party rights of individuals, in their facial challenge to the void statute. In Citizens United, the complaint, as drafted by James Bopp, made a very limited challenge to the bcra disclaimer regime. They said, this is not express advocacy, so no disclaimer is needed. The court held the Hillary movie was express advocacy or the equivalent, and therefor Bopp's argument, barely preserved by Paul Clement, lost. The rest of citizen united's high praise for disclosure and disclaimers, which they all lumped in together, unlike ACLF which had carefully distinguished them, was dicta, and does not controll this case. If it had, it would have been expressly overruled by town of vincent. Becerra is not an election case, but was narrowly focused on a disclaimer on a sign,and is far more on point. The view of NOM that CU had effectively overuled McIntyre was disproved or overuled by Janus, which reaffirmed a right to anonymity, again not in the election context. McIntyre did not create an exception for little old ladies. This misunderstanding led to statutes like Rhode Island's. Instead,the question presented was whether there was an elections exception to the rule of talley that disclaimer requirement are unconstitutional. What Rhode Island is doing is seeking to undermine the right of privacy underpinning Roe v Wade. This right was created by the trio civil rights cases in 1958-1960, NAACP, Bates v Little Rock, and Talley v California. Roe then extended this right to cover doctor-patient communications,and thus abortion. While the extension of the right to privacy to cover abortion in Roe is deeply controversial, only the supreme court, not the first circuit,can overturn Roe v Wade. The right to privacy recognized in Talley, McIntyre, ACLF, and Watchtower is the same right recognized in Roe. While Roe's holdings have been narrowed by Casey, it remains good law. Even if this court were to erroneously use the laxer standard of review rejected in McIntyre, the statute cannot withstand valeo's "exacting" scrutiny standard, because the state interests are not legitimate in light of the Rhode Island constitition. This is a point neither party raised in the briefing. The Rhode Island constitution protects both free speech and free elections. Threatening to jail those who spend $1000 on core politcal speech about elections is inconsistent ith these protections of the democratic process. The chilling effects of possible jail time distinguish this case from Citizens United (and perhaps NOM?). In Talley, the court held that a fine of $10 (in 1960 dollars) would chill speech. Jail is far more chilling. I've been there. In McIntyre, the court held that a fine of $100 (in 1995 dollars) would unconstitutionally chill speech. Due to covid, at the moment I am unable to access a copy of the Rhode Island constitution annotated. But the plain text is clear, and should not be ignored. [insert text here.] Section 6. Search and seizure. The right of the people to be secure in their persons, papers and possessions, against unreasonable searches and seizures, shall not be violated; The commandeering of the text of electioneering communications might be held to be a seizure. resume 7:32 Section 20. Freedom of press. The liberty of the press being essential to the security of freedom in a state, any person may publish sentiments on any subject, being responsible for the abuse of that liberty. Section 21. Right to assemble — Redress of grievances — Freedom of speech. The citizens have a right in a peaceable manner to assemble for their common good, and to apply to those invested with the powers of government, for redress of grievances, or for other purposes, by petition, address, or remonstrance. No law abridging the freedom of speech shall be enacted. The prohibition of speech which costs 1000 and does not contain the disclaimer violates the right of remonstrance, which has no direct federal analogue. The disclaimer rule violates the freedom of the press under section 20, and the right to free speech under 21. A $1000 sign or signs saying "vote for smith" is not an abuse of liberty. The disclaimer rule interferes with the right to assemble and petition. apparently no right to free elections. Section 1. Constitution supreme law of the state. This Constitution shall be the supreme law of the state, and any law inconsistent therewith shall be void. If, as I contend, the disclaimer statute is void as inconsistent with the state constitution, it is neither a legitimate nor compelling state interest.

1512-w-havens-st_kokomo-in-46901 clifford

7. draft letter to delaware legislators re sign case. dear representative or senator: I am writing to let you know about a problem with the delaware elections commission and its director (albence). A delaware statute, (section 81) is unconstitutional because it attempts to censor political signs by requiring an identification disclaimer. the supreme court first held in talley v california, in 1960 as part of the civil rights movement, that this violates the first amendment. In America if you want to put a sign in your yard that says "vote for smith", that is your right. The court has upheld this principle many times since then, such as recently in Becerra v NIFLA, which held that California cannot require disclaimers in pregnancy centers. In 1974 the Delaware Supreme Court ruled that a statute like this violates both the First Amendment and the Delaware constitution, in a case about whether the News Journal had to sign its editorials. I sued about this in 2000, in Anonymous v Delaware, but the court dismissed the case saying everyone agrees this is unconstitutional, so there was no controversy. I learned just last fall that in 2012 the legislature passed minor unimportant changes to the statute, which was still unconstitutional for the same reasons as before, but then in 2013 the elections department illegally started enforcing the void unconstitutional statute. There are several ways we can fix this. I wrote to the attorney general, kathy jennings, asking for an Attorney General Opinion but she has not answered my letter; I am merely a constituent. I think if you were to ask her she would issue such an opinion. Another option is legislative repeal. I would like to know whether you would support or oppose a bill to repeal this void unconstitutional statute. Would you sponsor or co-sponsor such a bill? Another possible outcome is that Albense might be criminally prosecuted, since his conduct violates federal law. I regard this outcome as unlikely. A next option will be for me to bring a court case, as I did in 2000. Such a case could be a class action, with the class being anyone who put the disclaimer on their campaign signs. That probably includes you. Would you like to be a coplaintiff in such a case? Alternatively, would you like to opt out? At the moment I am not licensed in Delaware; I grew up here but my law practice is based in Indianapolis. Do you happen to know anyone willing to serve as co-counsel? The way that I got involved in this issue is that someone once took down one of my campaign signs, because it did not have a disclaimer. The sign read, Robbin Stewart for Township Board - Vote Tuesday". A federal court held that the sign was protected speech, and struck down the Indiana statute. To summarize, I would like your help in requesting an AGO, your vote to repeal the void statute, and to let me know whether or not you want to be included in the lawsuit, if it gets that far. I'm happy to answer any questions. Gtbear@gmail.com is usually the best way to reach me. Sincerely, Robbin Stewart. 6:00 pm to 6:15 pm 6/8/21. to do: get list of reps and senators. https://legis.delaware.gov/Chambers/Senate/AssemblyMembers https://legis.delaware.gov/Chambers/House/AssemblyMembers 6:25. 0.45 hours. 6/ 8/21

4. first albence complaints.



to: 1. de ag office of publictrust@delaware.gov [https://attorneygeneral.delaware.gov/publictrust/complaint-form/] 820 N. French St. Wilmington, DE 19801 fbi William J. Green, Jr. Building

600 Arch Street, 8th Floor

Philadelphia, PA 19106

doj Voting Section

Civil Rights Division

U.S. Department of Justice

4 Constitution Square

Room 8.923

150 M Street, NE

Washington, DC 20530

Voting.Section@usdoj.gov .

New Castle County District Attorney 500 North King Street Wilmington, Delaware, 19801

cc: aclu

news journal editorial board

I am writing to bring to your attention that (albence) is illegally conspiring to violate the civil rights of Delawarians, especially those who use campaign signs. albense is the delaware director of elections. free elections are protected by the state and federal constitutions. free speech and press are protected by the state and federal constitutions.

what he is doing is threatening to fine people who make signs such as "vote for smith". such signs are core political speech.

that this is unconstitutional has been clearly established for the past 60 years, since talley v california in 1960. the state constitutional precedent was set in 1974, in a case that found that unsigned editorials at the news journal are protected by both constitutions. there are ten more supreme court cases backing up the holding in talley. the best known is mcintyre v ohio elections commission, which in 1995 held that ther eis no elections exception to the rule in talley that disclaimer requirements for political signs are unconstitutional.

albense is acting knowingly, willfully and intentionally. i have correspondence backing this up.

18 U.S. Code § 241 states: - Conspiracy against rights

If two or more persons conspire to injure, oppress, threaten, or intimidate any person in any State, Territory, Commonwealth, Possession, or District in the free exercise or enjoyment of any right or privilege secured to him by the Constitution or laws of the United States, or because of his having so exercised the same; or

If two or more persons go in disguise on the highway, or on the premises of another, with intent to prevent or hinder his free exercise or enjoyment of any right or privilege so secured—

They shall be fined under this title or imprisoned not more than ten years, or both; and if death results from the acts committed in violation of this section or if such acts include kidnapping or an attempt to kidnap, aggravated sexual abuse or an attempt to commit aggravated sexual abuse, or an attempt to kill, they shall be fined under this title or imprisoned for any term of years or for life, or both, or may be sentenced to death.

I have asked albense to cease and decist from his unlawful conduct. he has refused. i asked him to request an attorney general opinion, since recent cases like Becerra v NIFLA and Janus have superceded a previous AGO. There have been two opinions from the delaware attorney general on this topic. One claimed that the regulation is unconstitutional pre mcintyre (which is correct); the other claimed that the regulation is constitutional in spite of mcintyre, and made no mention of the 9 other controlling cases, including Anonymous v Delaware, when I sued about this in 2000. In that case, the court held that since both sides agreed the statute was obviously unconstitutional, there was no live controversy.

albense is the ringleader, but has conspired with at least 3 other people, probably more.

factors in his defense are, that he is acting pursuant to legislation, and the above-mentioned AGO. but, as the Nuremburg trials held, "just following orders" is no defense to criminal activity.

frankly, it is my expectation that since he is a government official, and y'all are government employees, that he will be given a free pass to continue his unlawful conduct. but today's motto is "see something, say something", and i have been unable to resolve the issue with lesser measures. he has been engaged in this malfeasance since 2013. I only learned of it in 2020. as an officer of the court, i have a professional duty to report such misconduct.

If you choose to investigate, I have various relevant letters and documents and am happy to cooperate. I can best be reached at gtbear@gmail.com.

Sincerely,

Robbin Stewart. 9:40 am- 10:19 am 6/8/21 tuesday. 0.66 hours. first draft. 10:35 0.9 hours. added addresses.

this space for writing a draft of a letter to the state department re my denied passport application. To: Western Passport Center 44132 Mercure Circle P.O. Box 1178 Sterling, Virginia 20166-1178 cc: todd young Sincerely, Customer Service Department Dear Customer Service Department, I have been trying to get my passport replaced for about 8 years. At one point i went to the passport office in buffalo, but they refused to reissue my passport because I don't know my passport number, and they claimed not to have computers to be able to look it up. So when i tried to enter canada i was turned back and put on some list, so i might never be able to go back to canada, our nearest neighbor and formost trading partner, which i used to visit routinely. in the years since then i have sent multiple letters requesting my passport number, but get an incomprehensible runaround instead of a simple answer to a simple question. i was a national merit scholarship, had a 4.0 in college, and have two law degrees, but i cannot wade through your thicket of red tape. i am now being threatened with not being able to visit my family in hawaii, because you won't issue me the passport i have properly applied for and paid for. i am disabled unemployed and indigent and cannot easily afford to lose the money i paid re my application. also, where i live in indiana they want to see a passport so i can vote. [i suspect this violates the 24th amendment, but that's another story.] I am trying to accomplish two things, both of which should be simple. I want to know what my passport number is. and i want a new passport, as per my application. You denied my application for two reasons. 1. the signature 2. the name change. As to the signature, I've been signing my name that way ever since the accident. I have regained the use of my right arm, and could probably manage to forge a signature that you woud like better, but then it wouldn't match the one on my driver's license, which you have a copy of. i suspect that your refusal to accept my signature, an X, violates the americans with disabilities act. it is unreasonable, arbitrary and capricious. my name is robbin george stewart. my signature is x. deal with it. As to the name change, the name on my birth certificate, which you are currently holding hostage, is richard lee stewart, and that was the name on my first passport in 1972, a family group type passport. but i changed my name as a minor and have been robbin george stewart ever since, which is the name on my passport, the one you won't tell me the number of, which probably expired around 1985, and was lost. So it is unreasonable for you to be demanding some complicated proof of my name - when it is the same name my passport is already in. i have looked over the rigamarole you want to me go through to show you i am me, and it is beyond my abilities. i am functionally illiterate; it has taken me years to get as far as this. all i am asking you to do is reissue me a new copy of the same passport i had before. it might be different if i were applying for the first time. i have filled out the right forms, included the right documents, paid my fee, and have the right to receive what i paid for. sincerely, robbin stewart.

U.S. Passport Application RE: 619790626 Inbox CA-PPT-WPC-eIRL Attachments Tue, Apr 20, 11:02 AM to me Your letter is attached in the PDF file above. You will also receive a copy of this letter via U.S. mail. DO NOT REPLY DIRECTLY TO THIS EMAIL BECAUSE THIS BOX IS UNMONITORED. RETURN A COPY OF THIS LETTER, ALONG WITH ALL REQUESTED INFORMATION, TO THE FOLLOWING ADDRESS: Western Passport Center 44132 Mercure Circle P.O. Box 1178 Sterling, Virginia 20166-1178 Sincerely, Customer Service Department DISCLAIMER This e-mail and any files transmitted with it are confidential and intended solely for the use of the individual to which they are addressed. If you are not the named addressee you should not disseminate, distribute or copy this email and are notified that doing so is strictly prohibited and may be unlawful. Please notify the sender immediately by telephone at 1-877-487-2778 if you have received this email in error and delete it from your system. Email transmission and accompanying files cannot be guaranteed to be secure or error-free as the information within could be intercepted, corrupted, lost, destroyed or incomplete, as well as possibly contain viruses or arrive late. The U.S. government and the U.S. Department of State assume no liability for any errors or omissions in the contents of this email transmission. Robbin G Stewart PO Box 29164 Indianapolis, IN 46229 RE: 619790626 Dear Mr. Stewart: We received your recent passport request. However, because you signed your application with a mark rather than your name, you will need one witness to attest to your exclusive use of a mark as your signature. To submit your application, please return to the acceptance facility where you originally applied, with the following: ➢ A new, completed application (Form DS-11, Application for a U.S. Passport). Do not sign it until instructed by the passport acceptance agent; ➢ Your witness will co-sign the Form DS-11, Applications for a U.S. Passport. Do not sign it until instructed by the passport acceptance agent; ➢ Your witness, with a new, completed Form DS-71, Affidavit of Identifying Witness; ➢ Identification; ➢ Passport photograph; and ➢ This letter. AND The application you submitted and your accompanying documents contain two different names. Your current name Robbin G. (George) Stewart must be documented. If your name has been legally changed, you must submit a certified copy of the court order or marriage certificate. The court orders must show the seal, date and judge’s signature. Photocopies and notarized copies are not acceptable. If your name has not been legally changed and you wish your passport to be written in your assumed name, please submit at least three certified or original public records, which show exclusive use of this name for at least five years and include your date and place of birth or your Social Security number (school, military, insurance, medical, etc.). Notarized affidavits completed by two people who have known you by both names may be substituted in place of one public record. Your evidence of U.S. citizenship has been retained by our office and will be returned to you once the application process is concluded. No additional execution fee will be charged if you return to the same acceptance facility where you initially applied. However, if you apply at a different acceptance facility, an additional execution fee must be paid directly to that acceptance facility. To assist with processing your application, we must receive the requested information within ninety (90) days of the date shown on this letter. If the information is not received or is insufficient to establish your entitlement to a U.S. passport, your application may be denied and your citizenship evidence will be returned. By law, the passport execution and application fees are non-refundable. United States Department of State Western Passport Center 44132 Mercure Circle PO Box 1178 Sterling, Virginia 20166-1178 April 20, 2021 If you have any questions, please contact the National Passport Information Center: 1-877-487-2778 (TTY/TDD: 1- 888-874-7793). For general passport information, to check the status of your passport application, please visit us on-line at travel.state.gov. PLEASE RETURN A COPY OF THIS LETTER, ALONG WITH ALL REQUESTED INFORMATION TO A PASSPORT ACCEPTANCE FACILITY. Sincerely, Customer Service Department Enclosure(s): DS-11, Application for Passport DS-60(2), Affidavit Regarding a Change of Name JM/ed * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * For Acceptance Agents Only ❑ Accept completed DS-11 Application of a U.S. Passport, identification, and one photo from the above-mentioned customer. In addition, please accept the completed DS-71, Affidavit of Identifying Witness. (They are returning to your office because an execution error was made when the application was initially filed at your office.) ❑ Execute the application and the affidavit. ❑ Please do not collect the execution fee. ❑ Attach this letter to the application. ❑ Send the executed application to the address indicated on this letter. * * * * * * * AFFIDAVIT REGARDING A CHANGE OF NAME WARNING False statements made knowingly and willfully on passport applications or on affidavits or other supporting documents submitted therewith are punishable by fine and/or imprisonment under the provisions of 18 U.S.C. 1001, 18 U.S.C. 1542, and/or 18 U.S.C. 1621. Alteration or mutilation of a passport issued pursuant to this application is punishable by fine and/or imprisonment under the provisions of 18 U.S.C. 1543. The use of a passport in violation of the restrictions contained therein or of the passport regulations is punishable by fine and/or imprisonment under 18 U.S.C. 1544. All statements and documents are subject to verification. 2. Approximate Date Current Name Was Assumed (mm-yyyy) 3. Former Name of Applicant 4. Applicant's Date of Birth Last Suffix First Middle 6. Number of Years You Have Known the Applicant 7. Your Relationship to the Applicant By Current Name By Former Name Explain the variance in the applicant's name shown on his/her birth records and the name currently used. State whether the current name is used exclusively and for all purposes or if it is used as an "also known as" name. Continue on the back of this form if additional space is required. I solemnly swear (or affirm) that the information given above by me is true and correct to the best of my knowledge and belief; that the applicant named above has been known by both his or her present and former names as stated and is one and the same person; that the applicant is known by his or her present name to friends and relatives, and in the community in which he or she is residing. (Jr.,Sr.,III) (mm-dd-yyyy) (City and State) (or Name Given on Birth Records) Last Suffix First (Jr.,Sr.,III) Middle PURPOSE An Affidavit Regarding a Change of Name may be submitted with an application for a U.S. passport when the name which is used by the applicant is (1) substantially different from that shown on the evidence of citizenship or (2) has been adopted without formal court proceedings and was not acquired by a marriage. The affiant (preferably a blood relative) must have personal knowledge of the applicant's use of both names. To support a change of name that has been adopted without formal court proceedings or by a marriage, the applicant must present original or certified copies of three or more public documents evidencing that the applicant has used the acquired name generally for five years or longer. Affidavits Regarding a Change of Name from at least two persons, attesting that they have known the applicant by both names and that the applicant has used the new name generally for at least five years, may be provided in place of one of the public documents if the applicant cannot obtain a third public document. The affidavit must be accompanied by a photocopy of the front and back of the affiant's identification. Final determination of the name(s) to be shown in the U.S. passport will be made by Passport Services based on all submitted evidence. Completed affidavits will be retained and requests for copies of this affidavit should be made at the time of execution. An affidavit does not need to be submitted if an applicant can present a court order documenting the change of their name. U.S. Department of State OMB APPROVAL NO. 1405-0133 EXPIRES: 09-30-2017 ESTIMATED BURDEN: 40 MINUTES Address of Affiant Identifying Document Submitted (Type of Document, Date of Issuance and/or Expiration, Document Number) Subscribed and Sworn to before me this day of at Name of Passport Agent, Acceptance Agent, or Notary Public Location DS-60 01-2014 Page 1 of 2 (SEAL) (Number and Street, City, State, and Zip Code ) (Affirmed) (Passport Agency or City and State) 1. Current Name of Applicant Printed Name of Affiant Signature of Affiant Affiant's Social Security Number 5. Applicant's Place of Birth Please Print Legibly Using Black Ink Only. For Additional Comments DS-60 Page 2 of 2 PRIVACY ACT STATEMENT PAPERWORK REDUCTION ACT STATEMENT AUTHORITIES: We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E; Executive Order 11295 (August 5, 1966); and 22 C.F.R. parts 50 and 51. PURPOSE: We are requesting this information in order to establish the identity ofthe subject of this affidavit as part of the subject's application for a U.S. passport. The collection of the Social Security number will be used to verify your identity and for no other purpose unless authorized by law. ROUTINE USES: This information may be disclosed to another domestic government agency, a private contractor, a foreign government agency, or to a private person or private employer in accordance with certain approved routine uses. These routine uses include, but are not limited to, law enforcement activities, employment verification, fraud prevention, border security, counterterrorism, litigation activities, and activities that meet the Secretary of State's responsibility to protect U.S. citizens and non-citizen nationals abroad. More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas Citizen Services Records and State-26, Passport Records. DISCLOSURE: Providing your Social Security number and the other information on this form is voluntary, but failure to provide the information on this form may, given the form's purpose of verification of identity and... Visit the official Department of State website at travel.state.gov or contact the National Passport Information Center (NPIC) via toll-free at 1-877-487-2778 (TDD: 1-888-874-7793) and NPIC@state.gov. Customer Service Representatives are available Monday-Friday 8:00a.m.-10:00p.m. Eastern Time (excluding federal holidays). Automated information is available 24 hours a day, 7 days a week. U.S. PASSPORT APPLICATION DS-11 06-2016 Instruction Page 1 of 4 WHAT TO SUBMIT WITH THIS FORM: 1. PROOF OF U.S. CITIZENSHIP: Evidence of U.S. citizenship AND a photocopy of the front (and back, if there is printed information) must be submitted with your application. The photocopy must be on 8 1⁄2 inch by 11 inch paper, black and white ink, legible, and clear. Evidence that is not damaged, altered, or forged will be returned to you. Note: Lawful permanent resident cards submitted with this application will be forwarded to U.S. Citizenship and Immigration Services, if we determine that you are a U.S. citizen. 2. PROOF OF IDENTITY: You must present your original identification AND submit a photocopy of the front and back with your passport application. 3. RECENT COLOR PHOTOGRAPH: Photograph must meet passport requirements – full front view of the face and 2x2 inches in size. 4. FEES: Please visit our website at travel.state.gov for current fees. HOW TO SUBMIT THIS FORM: Complete and submit this application in person to a designated acceptance agent: a clerk of a federal or state court of record or a judge or clerk of a probate court accepting applications; a designated municipal or county official; a designated postal employee at an authorized post office; an agent at a passport agency (by appointment only); or a U.S. consular official at a U.S. Embassy or Consulate, if abroad. To find your nearest acceptance facility, visit travel.state.gov or contact the National Passport Information Center at 1-877-487-2778. LOST OR STOLEN - If you cannot submit your valid or potentially valid U.S. passport book and/or passport card with this application and you have not previously submitted Form DS-64, Statement Regarding a Lost or Stolen U.S. Passport, you are required to fill out and submit a DS-64 with this application. IN MY POSSESSION - If your most recent U.S.passport book and/or passport card was issued less than 15 years ago, and you were over the age of 16 at the time of issuance, you may be eligible to use Form DS-82 to renew your passport by mail. Follow the instructions on Page 2 for detailed information to completion and submission of this form. If you are 16 years of age or older: Your U.S. passport will be valid for 10 years from the date of issue except where limited by the Secretary of State to a shorter period. If you are under 16 years of age: Your U.S. passport will be valid for five years from the date of issue except where limited by the Secretary of State to a shorter period. PASSPORT VALIDITY LENGTH PLEASE DETACH AND RETAIN THIS INSTRUCTION SHEET FOR YOUR RECORDS  The passport application fee, security surcharge, and expedite fee may be paid in any of the following forms: Checks (personal, certified, or traveler's) with the applicant's full name and date of birth printed on the front; major credit card (Visa, Master Card, American Express, and Discover); bank draft or cashier's check; money order (U.S. Postal, international, currency exchange), or if abroad, the foreign currency equivalent, or a check drawn on a U.S. bank. All fees should be payable to the "U.S. Department of State" or if abroad, the appropriate U.S. Embassy or U.S. Consulate. When applying at a designated acceptance facility, the execution fee will be paid separately and should be made payable to the acceptance facility. NOTE: Some designated acceptance facilities do not accept credit cards as a form of payment.  For faster processing, you may request expedited service. Please include the expedite fee in your payment. Our website contains updated information regarding fees and processing times for expedited service. Expedited service is only available for passports mailed in the United States and Canada.  OVERNIGHT DELIVERY SERVICE is only available for passport book mailings in the United States. Please include the appropriate fee with your payment.  An additional fee will be charged when, upon your request, the U.S. Department of State verifies issuance of a previous U.S. passport or Consular Report of Birth Abroad because you are unable to submit evidence of U.S. citizenship.  For applicants with U.S. government or military authorization for no-fee passports, no fees are charged except the execution fee when applying at a designated acceptance facility. PROOF OF U.S. CITIZENSHIP You may submit items such as the following containing your signature AND a photograph that is a good likeness of you: previous or current U.S. passport book; previous or current U.S. passport card; driver's license (not temporary or learner's license); Certificate of Naturalization; Certificate of Citizenship; military identification; or federal, state, or municipal government employee identification card. Temporary or altered documents are not acceptable. You must establish your identity to the satisfaction of the acceptance agent and Passport Services. We may ask you to provide additional evidence to establish your identity. If you have changed your name, please see travel.state.gov for instructions. IF YOU CANNOT PROVIDE DOCUMENTARY EVIDENCE OF IDENTITY as stated above, you must appear with an IDENTIFYING WITNESS, who is a U.S. citizen, non-citizen U.S. national, or permanent resident alien that has known you for at least two years. Your witness must prove his or her identity and complete and sign an Affidavit of Identifying Witness (Form DS-71) before the acceptance agent. You must also submit some identification of your own. Submit a color photograph of you alone, sufficiently recent to be a good likeness of you (taken within the last six months), and 2x2 inches in size. The image size measured from the bottom of your chin to the top of your head (including hair) should not be less than 1 inch, and not more than 1 3/8 inches. The photograph must be in color, clear, with a full front view of your face. The photograph must be taken with a neutral facial expression (preferred) or a natural smile, and with both eyes open and be printed on photo quality paper with a plain light (white or off-white) background. The photograph must be taken in normal street attire, without a hat, or head covering unless a signed statement is submitted by the applicant verifying that the hat or head covering is part of recognized, traditional religious attire that is customarily or required to be worn continuously when in public or a signed doctor's statement is submitted verifying the item is used daily for medical purposes. Headphones, "bluetooth", or similar devices must not be worn in the passport photograph. Glasses or other eyewear are not acceptable unless you provide a signed statement from a doctor explaining why you cannot remove them due to medical reasons (e.g., during the recovery period from eye surgery). Any photograph retouched so that your appearance is changed is unacceptable. A snapshot, most vending machine prints, hand-held self portraits, and magazine or full-length photographs are unacceptable. A digital photo must meet the previously stated qualifications, and will be accepted for use at the discretion of Passport Services. Visit our website at travel.state.gov for details and information. FEES ARE LISTED ON OUR WEBSITE AT TRAVEL.STATE.GOV. BY LAW, THE PASSPORT FEES ARE NON-REFUNDABLE. DS-11 06-2016 PROOF OF IDENTITY COLOR PHOTOGRAPH FEES Instruction Page 2 of 4 APPLICANTS BORN IN THE UNITED STATES: Submit a previous U.S. passport or certified birth certificate. Passports that are limited in validity will need to be supplemented by other evidence. A birth certificate must include your full name, date and place of birth, sex, date the birth record was filed, the seal or other certification of the official custodian of such records (state, county, or city/town office), and the full names of your parent(s). - If the birth certificate was filed more than 1 year after the birth: It must be supported by evidence described in the next paragraph. - If no birth record exists: Submit a registrar's notice to that effect. Also, submit a combination of the evidence listed below, which should include your given name and surname, date and/or place of birth, and the seal or other certification of the office (if customary), and the signature of the issuing official.  A hospital birth record;  An early baptismal or circumcision certificate;  Early census, school, medical, or family Bible records;  Insurance files or published birth announcements (such as a newspaper article); and  Notarized affidavits (or DS-10, Birth Affidavit) of older blood relatives having knowledge of your birth may be submitted in addition to some of the records listed above. APPLICANTS BORN OUTSIDE THE UNITED STATES: Submit a previous U.S. passport, Certificate of Naturalization, Certificate of Citizenship, Consular Report of Birth Abroad, or evidence described below: - If you claim citizenship through naturalization of parent(s): Submit the Certificate(s) of Naturalization of your parent(s), your foreign birth certificate (and official translation if the document is not in English), proof of your admission to the United States for permanent residence, and your parents' marriage/certificate and/or evidence that you were in the legal and physical custody of your U.S. citizen parent, if applicable. - If you claim citizenship through birth abroad to at least one U.S. citizen parent: Submit a Consular Report of Birth (Form FS-240), Certification of Birth (Form DS-1350 or FS-545), or your foreign birth certificate (and official translation if the document is not in English), proof of U.S. citizenship of your parent, your parents' marriage certificate, and an affidavit showing all of your U.S. citizen parents' periods and places of residence/physical presence in the United States and abroad before your birth. - If you claim citizenship through adoption by a U.S. citizen parent(s): Submit evidence of your permanent residence status, full and final adoption, and your U.S. citizen parent(s) evidence of legal and physical custody. (NOTE: Acquisition of U.S. citizenship for persons born abroad and adopted only applies if the applicant was born on or after 02/28/1983.) ADDITIONAL EVIDENCE: You must establish your citizenship to the satisfaction of the acceptance agent and Passport Services. We may ask you to provide additional evidence to establish your claim to U.S. citizenship. Visit travel.state.gov for details. DS-11 06-2016 FEDERAL TAX LAW Section 6039E of the Internal Revenue Code (26 U.S.C. 6039E) and 22 U.S.C 2714a(f) require you to provide your Social Security number (SSN), if you have one, when you apply for or renew a U.S. passport. If you have never been issued a SSN, you must enter zeros in box #5 of this form. If you are residing abroad, you must also provide the name of the foreign country in which you are residing. The U.S. Department of State must provide your SSN and foreign residence information to the U.S. Department of the Treasury. If you fail to provide the information, your application may be denied and you are subject to a $500 penalty enforced by the IRS. All questions on this matter should be referred to the nearest IRS office. If you send us a check, it will be converted into an electronic funds transfer (EFT). This means we will copy your check and use the account information on it to electronically debit your account for the amount of the check. The debit from your account will usually occur within 24 hours and will be shown on your regular account statement. You will not receive your original check back. We will destroy your original check, but we will keep the copy of it. If the EFT cannot be processed for technical reasons, you authorize us to process the copy in place of your original check. If the EFT cannot be completed because of insufficient funds, we may try to make the transfer up to two times, and we will charge you a one-time fee of $25, which we will also collect by EFT. NOTICE TO CUSTOMERS APPLYING OUTSIDE A DEPARTMENT OF STATE FACILITY Passport service fees are established by law and regulation (see 22 U.S.C. 214, 22 C.F.R. 22.1, and 22 C.F.R. 51.50-56), and are collected at the time you apply for the passport service. If the Department fails to receive full payment of the applicable fees because, for example, your check is returned for any reason or you dispute a passport fee charge to your credit card, the U.S. Department of State will take action to collect the delinquent fees from you under 22 C.F.R. Part 34, and the Federal Claims Collection Standards (see 31 C.F.R. Parts 900-904). In accordance with the Debt Collection Improvement Act (Pub.L. 104-134), if the fees remain unpaid after 180 days and no repayment arrangements have been made, the Department will refer the debt to the U.S. Department of Treasury for collection. Debt collection procedures used by U.S. Department of Treasury may include referral of the debt to private collection agencies, reporting of the debt to credit bureaus, garnishment of private wages and administrative offset of the debt by reducing, or withholding eligible federal payments (e.g., tax refunds, social security payments, federal retirement, etc.) by the amount of your debt, including any interest penalties or other costs incurred. In addition, non-payment of passport fees may result in the invalidation of your passport. An invalidated passport cannot be used for travel. FEE REMITTANCE USE OF SOCIAL SECURITY NUMBER For more information regarding reporting a lost or stolen U.S. passport book or passport card (Form DS-64), or to determine your eligibility for a passport renewal (Form DS-82), call NPIC at 1-877-487-2778 or visit travel.state.gov. Your Social Security number will be provided to U.S. Department of Treasury, used in connection with debt collection and checked against lists of persons ineligible or potentially ineligible to receive a U.S. passport, among other authorized uses. PROTECT YOURSELF AGAINST IDENTITY THEFT! REPORT YOUR LOST OR STOLEN PASSPORT BOOK OR PASSPORT CARD! NOTICE TO APPLICANTS FOR OFFICIAL, DIPLOMATIC, OR NO-FEE PASSPORTS You may use this application if you meet all of the provisions listed on Instruction Page 2; however, you must CONSULT YOUR SPONSORING AGENCY FOR INSTRUCTIONS ON PROPER ROUTING PROCEDURES BEFORE FORWARDING THIS APPLICATION. Your completed passport will be released to your sponsoring agency for forwarding to you. Passport Services will not mail a U.S. passport to a private address outside the United States or Canada. If you do not live at the address listed in the "mailing address", then you must put the name of the person and mark it as "In Care Of" in item # 8. If your mailing address changes prior to receipt of your new passport, please contact the National Passport Information Center. If you choose to provide your email address in Item #6 on this application, Passport Services may use that information to contact you in the event there is a problem with your application or if you need to provide information to us. You may receive your newly issued passport book and/or card and your returned citizenship evidence in two separate mailings. If you are applying for both a U.S. passport book and passport card, you may receive three separate mailings; one with your returned citizenship evidence, one with your newly issued passport book, and one with your newly issued passport card. NOTICE TO U.S. PASSPORT CARD APPLICANTS The maximum number of letters provided for your given name (first and middle) on the U.S. passport card is 24 characters. The 24 characters may be shortened due to printing restrictions. If both your given names are more than 24 characters, you must shorten one of your given names you list on item 1 of this form. U.S. passports, either in book or card format, are only issued to U.S. citizens or non-citizen U.S. nationals. Each person must obtain his or her own U.S. passport book or U.S. passport card. The passport card is a U.S. passport issued in card format. Like the traditional U.S. passport book, it reflects the bearer's origin, identity, and nationality, and is subject to existing passport laws and regulations. Unlike the U.S. passport book, the U.S. passport card is valid only for entry at land border crossings and sea ports of entry when traveling from Canada, Mexico, the Caribbean, and Bermuda. The U.S. passport card is not valid for international air travel. NOTE REGARDING MAILING OF YOUR PASSPORT(S) Instruction Page 3 of 4 DS-11 06-2016 ACTS OR CONDITIONS If any of the below-mentioned acts or conditions have been performed by or apply to the applicant, the portion which applies should be lined out, and a supplementary explanatory statement under oath (or affirmation) by the applicant should be attached and made a part of this application. I have not, since acquiring United States citizenship/nationality, been naturalized as a citizen of a foreign state; taken an oath or made an affirmation or other formal declaration of allegiance to a foreign state; entered or served in the armed forces of a foreign state; accepted or performed the duties of any office, post, or employment under the government of a foreign state or political subdivision thereof; made a formal renunciation of nationality either in the United States, or before a diplomatic or consular officer of the United States in a foreign state; or been convicted by a court or court martial of competent jurisdiction of committing any act of treason against, or attempting by force to overthrow, or bearing arms against, the United States, or conspiring to overthrow, put down, or to destroy by force, the government of the United States. Furthermore, I have not been convicted of a federal or state drug offense or convicted of a "sex tourism" crimes statute, and I am not the subject of an outstanding federal, state, or local warrant of arrest for a felony; a criminal court order forbidding my departure from the United States; a subpoena received from the United States in a matter involving federal prosecution for, or grand jury investigation of, a felony. PRIVACY ACT STATEMENT AUTHORITIES: Collection of this information is authorized by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E, 22 U.S.C. 2714a(f), Section 236 of the Admiral James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001; Executive Order 11295 (August 5, 1966); and 22 C.F.R. parts 50 and 51. PURPOSE: We are requesting this information in order to determine your eligibility to be issued a U.S. passport. Your Social Security number is used to verify your identity. ROUTINE USES: This information may be disclosed to another domestic government agency, a private contractor, a foreign government agency, or to a private person or private employer in accordance with certain approved routine uses. These routine uses include, but are not limited to, law enforcement activities, employment verification, fraud prevention, border security, counterterrorism, litigation activities, and activities that meet the Secretary of State's responsibility to protect U.S. citizens and non-citizen nationals abroad. More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas Citizen Services Records and State-26, Passport Records. DISCLOSURE: Providing information on this form is voluntary. Be advised, however, that failure to provide the information requested on this form may cause delays in processing your U.S. passport application and/or could result in the refusal or denial of your application. Failure to provide your Social Security number may result in the denial of your application (consistent with 22 U.S.C. 2714a(f)) and may subject you to a penalty enforced by the Internal Revenue Service, as described in the Federal Tax Law section of the instructions to this form. Your Social Security number will be provided to the Department of the Treasury and may be used in connection with debt collection, among other purposes authorized and generally described in this section. ELECTRONIC PASSPORT STATEMENT The U.S. Department of State now issues an "Electronic Passport" book, which contains an embedded electronic chip. The electronic passport book continues to be proof of the bearer's U.S. citizenship/nationality and identity, and looks and functions in the same way as a passport without a chip. The addition of an electronic chip in the back cover enables the passport book to carry a duplicate electronic copy of all information from the data page. The electronic passport book is usable at all ports-of-entry, including those that do not yet have electronic chip readers. Use of the electronic format provides the traveler the additional security protections inherent in chip technology. Moreover, when used at ports-of-entry equipped with electronic chip readers, the electronic passport book provides for faster clearance through some of the port-of-entry processes. The electronic passport book does not require special handling or treatment, but like previous versions should be protected from extreme heat, bending, and from immersion in water. The electronic chip must be read using specially formatted readers, which protects the data on the chip from unauthorized reading. The cover of the electronic passport book is printed with a special symbol representing the embedded chip. The symbol will appear in port-of-entry areas where the electronic passport book can be read. PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is estimated to average 85 minutes per response, including the time required for searching existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: U.S. Department of State, Bureau of Consular Affairs, Passport Services, Office of Legal Affairs and Law Enforcement Liaison, 44132 Mercure Cir, P.O. Box 1227, Sterling, Virginia 20166-1227 Instruction Page 4 of 4 4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.) APPLICATION FOR A U.S. PASSPORT DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY AUTHORIZED AGENT OMB CONTROL NO. 1405-0004 OMB EXPIRATION DATE: 08-31-2019 ESTIMATED BURDEN: 85 MIN Please Print Legibly Using Black Ink Only Attention: Read WARNING on page 1 of instructions Please select the document(s) for which you are applying: D O Dep End. # Exp. First Middle - - M F A. B. DOTS 3. Sex STOP! CONTINUE TO PAGE 2 U.S. Passport Book U.S. Passport Card Note: The 52 page option is for those who frequently travel abroad during the passport validity period, and is recommended for applicants who have previously required the addition of visa pages. Large Book (Non-Standard) - - City Zip Code 6. Email (Info alerts offered at travel.state.gov) @ 7. Primary Contact Phone Number - - 1. Name Last State Country, if outside the United States 9. List all other names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change. Attach additional pages if needed) 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) x x Mother/Father/Parent/Legal Guardian's Signature (if identifying minor) x Mother/Father/Parent/Legal Guardian's Signature (if identifying minor) Applicant's Legal Signature - age 16 and older I declare under penalty of perjury all of the following: 1) I am 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 Conditions" 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) I have not knowingly and willfully made false statements or included false documents in support of this application; 4) the photograph attached to this application is a genuine, current photograph of me; and 5) I have read and understood the warning on page one of the instructions to the application form. (Seal) Acceptance Agent (Vice) Consul USA Passport Staff Agent For Issuing Office Only Bk EF Postage Execution Other * DS 11 A 09 2013 1 * Date Facility Name/Location Identifying Documents - Applicant or Mother/Father/Parent on Second Signature Line (if identifying minor) DS-11 06-2016 Page 1 of 2 Facility ID Number Agent ID Number Signature of person authorized to accept applications Card Driver's License ID No Passport Military Other Country of Issuance State Issued ID Card Identifying Documents - Applicant or Mother/Father/Parent on Third Signature Line (if identifying minor) STAPLE 2" x 2" STAPLE STAPLE 2" x 2" STAPLE Attach a color photograph taken within the last six months Name Driver's License ID No Issue Date (mm/dd/yyyy) Exp. Date (mm/dd/yyyy) State of Issuance Passport Military Other 8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB. 5. Social Security Number 2. Date of Birth (mm/dd/yyyy) Both Regular Book (Standard) The U.S. passport card is not valid for international air travel. For more information see page 1 of instructions. Country of Issuance State Issued ID Card Name Name of courier company (if applicable) Issue Date (mm/dd/yyyy) Exp. Date (mm/dd/yyyy) State of Issuance 18. Travel Plans Departure Date (mm/dd/yyyy) Return Date (mm/dd/yyyy) Countries to be Visited Apartment/Unit 19. Permanent Address - If P.O. Box is listed under Mailing Address or if residence is different from Mailing Address. Street/RFD # or URB (No P.O. Box) 13. Occupation (if age 16 or older) 14. Employer or School (if applicable) Home Cell Work 12. Additional Contact Phone Number Mother/Father/Parent - First & Middle Name Last Name (at Parent's Birth) Date of Birth (mm/dd/yyyy) Place of Birth 10. Parental Information Male Female Yes No Sex U.S. Citizen? Name of Applicant (Last, First, & Middle) Date of Birth (mm/dd/yyyy) - - Mother/Father/Parent - First & Middle Name Last Name (at Parent's Birth) Date of Birth (mm/dd/yyyy) Place of Birth Male Female Yes No Sex U.S. Citizen? - - - - If yes, complete the remaining items in #11. Date of Marriage (mm/dd/yyyy) 11. Have you ever been married? Full Name of Current Spouse or Most Recent Spouse Date of Birth (mm/dd/yyyy) Have you ever been widowed or divorced? Place of Birth Yes No Widow/Divorce Date (mm/dd/yyyy) Yes No Yes No U.S. Citizen? - - 15. Height 16. Hair Color 17. Eye Color City State Zip Code 21. Have you ever applied for or been issued a U.S. Passport Book or Passport Card? Name as printed on your most recent passport book Yes No If yes, complete the remaining items in #21. PLEASE DO NOT WRITE BELOW THIS LINE - FOR ISSUING OFFICE ONLY 20. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency. Name Address: Street/RFD # or P.O. Box Apartment/Unit City State Zip Code Phone Number Relationship Name as printed on your most recent passport card Status of your most recent passport book: Submitting with application Stolen Lost In my possession (if expired) Status of your most recent passport card: Submitting with application Stolen Lost In my possession (if expired) Most recent passport book number Most recent passport book issue date (mm/dd/yyyy) Most recent passport card number Most recent passport card issue date (mm/dd/yyyy) * DS 11 A 09 2013 2 *

THE OFFICE OF SENATOR TODD YOUNG 493 Russell Senate Office Building ● Washington, DC 20515 (202) 224-5623 ● (202) 224-1845 (fax) PASSPORT INTAKE INFORMATION Name of applicant: _robbin george stewart_______________________________ (M__x_ F___) Address: ________residence: 4015 e washington st indy in 46201. mailing: po box 29164 indy in 46229____________________________________________________________ ____________________________________________________________________________ Phone(s): __________no phone.__________________________________________________________ E-mail: _______________gtbear@gmail.com______________________________________________________ Date of Birth: _8/11/1960_______________________________________________________________ Social Security # 222-34-5483. I suspect that this demand for my ssn, with out a privacy act statement, violates the privacy act. i'm not complaining, just thought you might want to know._______-_____-_______ Choose one: I have not yet applied: _________ I have applied: x_________ Date of application: _couple months ago?_____________________ Locator Number (if known): _______619790626________ Service Request: ___ New __x_ Renewal ___ Extra Pages ___ Name Change ___ Expedited Service or ___ Regular Service Date of travel: _____na____________________________________________________________ Destination: __________________________________________________________________ Visa Needed: Y____ N__x__ PLEASE RETURN THIS FORM TO: Senator Todd Young 3602 Northgate Court, Suite 15 New Albany, IN 47150 Phone: (812) 542-4820 Fax: (812) 542-4826 THE OFFICE OF SENATOR TODD YOUNG 493 Russell Senate Office Building ● Washington, DC 20515 (202) 224-5623 ● (202) 224-1845 (fax) PASSPORT INTAKE INFORMATION Name of applicant: __________________________________________________ (M___ F___) Address: ____________________________________________________________________ ____________________________________________________________________________ Phone(s): ____________________________________________________________________ E-mail: _____________________________________________________________________ Date of Birth: ________________________________________________________________ Social Security # _______-_____-_______ Choose one: I have not yet applied: _________ I have applied: _________ Date of application: ______________________ Locator Number (if known): _______________ Service Request: ___ New ___ Renewal ___ Extra Pages ___ Name Change ___ Expedited Service or ___ Regular Service Date of travel: _________________________________________________________________ Destination: __________________________________________________________________ Visa Needed: Y____ N____ PLEASE RETURN THIS FORM TO: Senator Todd Young 3602 Northgate Court, Suite 15 New Albany, IN 47150 Phone: (812) 542-4820 Fax: (812) 542-4826

Senator Todd Young Phone: (812) 542-4820 Indiana Fax: (812) 542-4826 GENERAL Consent for Release of Personal Records by Executive Agencies Please complete and return to the following address: Senator Todd Young 3602 Northgate Ct., Suite 15 New Albany, IN 47150 *Name of Claimant: _____robbin george stewart__________________________________________________ (First) (M.I.) (Last) *Mailing Address: _______4015 e washington st indy in 46201_________________________________________________ (Street) ________________________________________________________ (City) (State) (Zip) *Home Phone: ___none_____________________Alternate Phone: __3177601277___________________ *Date of Birth: _______08 11 1960________________ Email: _____________________________ HOUSEHOLD INFORMATION: Does claimant have a spouse or dependent children? If so, please list names and ages: NA ________________________________________________________________________ IDENTIFICATION NUMBERS: *Social Security: ____222 34 5483. this demand for my social security number, without a privacy act statement, is an apparent violation of the privacy act. not complaining, just thought you might want to know.____________________ Other ID Number: _______________________ CLAIM HISTORY: Has a claim already been filed? ____ Yes ____ No Date (or approximate date) claim filed: ________________________________________ What type of benefits have you applied for: _____________________________________ At which office did you apply? state department passport office______________________________________________ HOW DID YOU HEAR ABOUT US? ___Friend/Relative ___Social Media ___Website ___Mail _x__Elected Official ___Mobile Offices ___Town Hall ___Other Senator Todd Young Phone: (812) 542-4820 Indiana Fax: (812) 542-4826 Have you contacted any other elected officials about this problem? If yes, who? _____don't think so._________ ______________________________________________________________________________ ______________________________________________________________________________ *BRIEFLY DESCRIBE PROBLEM OR INQUIRY: ___________applied for passport. got rejected for two reasons. 1, they don't like my signature, which is an x. 2. they are unhappy that i changed my name in 1979 as a teenager. no records currently exist of the name change. my previous passport, lost circa 1985, was in my current name.__________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ *PLEASE EXPLAIN WHAT YOU WOULD LIKE FOR SENATOR YOUNG TO DO ON YOUR BEHALF (please print clearly): ______________________________________________________________________________two things, one easy, the other maybe more difficult. i would like to know my passport number. can't get them to tell me. have been asking for years. maybe they will tell you. second, i want help getting my passport. i have applied for it, sent in my driver's license, birth certificate, and fee, and believe i am entitled to it. if they continue to refuse to issue it, i at least want my money back. i cannot afford to pay something for nothing. although i think they are bluffing, they have been saying that as of october, they won't let me fly to hawaii without a passport, since indiana refuses to issue me a real ID. i also would like to get my passport to be able to vote in indiana. i have been denied the vote on about 7 occasions since the voter ID statute went in place in 2006. and i have been invited on a cruise to europe, but i can't go without a passport. that's the general idea. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________________ ______________________________________________________________________________ If you wish to authorize the release of information regarding your case to a relative or third party, please provide their names: ______________________________________________________________________________ ______________________________________________________________________________ I have sought assistance from Senator Young on a matter that may require the release of information maintained by your agency, and which you may be prohibited from disseminating under the Privacy Act of 1974. I hereby authorize Senator Todd Young, or any member of his staff, to work on my behalf with any Federal Agency involved in this case. Agencies may release any relevant information contained in my file/records, forward pertinent correspondence sent to me, or discuss issues relevant to my case, all of which may be used by the Senator’s office until the matter is resolved. I also affirm that the above information is accurate, to the best of my knowledge, under penalty of perjury. **SIGNATURE: ______x [that is my signature]_______________________________ DATE: _6/6/21____________ *Required Information Senator Todd Young Phone: (812) 542-4820 Indiana Fax: (812) 542-4826 GENERAL Consent for Release of Personal Records by Executive Agencies Please complete and return to the following address: Senator Todd Young 3602 Northgate Ct., Suite 15 New Albany, IN 47150 *Name of Claimant: _______________________________________________________ (First) (M.I.) (Last) *Mailing Address: ________________________________________________________ (Street) ________________________________________________________ (City) (State) (Zip) *Home Phone: ________________________Alternate Phone: _____________________ *Date of Birth: _______________________ Email: _____________________________ HOUSEHOLD INFORMATION: Does claimant have a spouse or dependent children? If so, please list names and ages: ________________________________________________________________________ IDENTIFICATION NUMBERS: *Social Security: ________________________ Other ID Number: _______________________ CLAIM HISTORY: Has a claim already been filed? ____ Yes ____ No Date (or approximate date) claim filed: ________________________________________ What type of benefits have you applied for: _____________________________________ At which office did you apply? ______________________________________________ HOW DID YOU HEAR ABOUT US? ___Friend/Relative ___Social Media ___Website ___Mail ___Elected Official ___Mobile Offices ___Town Hall ___Other Senator Todd Young Phone: (812) 542-4820 Indiana Fax: (812) 542-4826 Have you contacted any other elected officials about this problem? If yes, who? ______________ ______________________________________________________________________________ ______________________________________________________________________________ *BRIEFLY DESCRIBE PROBLEM OR INQUIRY: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ *PLEASE EXPLAIN WHAT YOU WOULD LIKE FOR SENATOR YOUNG TO DO ON YOUR BEHALF (please print clearly): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ If you wish to authorize the release of information regarding your case to a relative or third party, please provide their names: ______________________________________________________________________________ ______________________________________________________________________________ I have sought assistance from Senator Young on a matter that may require the release of information maintained by your agency, and which you may be prohibited from disseminating under the Privacy Act of 1974. I hereby authorize Senator Todd Young, or any member of his staff, to work on my behalf with any Federal Agency involved in this case. Agencies may release any relevant information contained in my file/records, forward pertinent correspondence sent to me, or discuss issues relevant to my case, all of which may be used by the Senator’s office until the matter is resolved. I also affirm that the above information is accurate, to the best of my knowledge, under penalty of perjury. **SIGNATURE: _____________________________________ DATE: _____________ *Required Information

wednesday

missed lawyer zoom. to do: email mark small.

shopping list: raisins. bread. cider? x insulin cocoa.? order online. or check shelves at acme.

x what else? call tommy.

x/2 work on those disclaimer emails. check email.

did: figured out how to print at ups. printed letter to kathy jennings. biked to ups, picked up documents. mailed 1 copy to home address, one copy to campaign office. should make another copy to snailmail to office address. took about an hour. 1.0 hours june 2 2021. $1.40 in printing and postage. involved research to find her home and campaign address, since she is not responding to documents sent to office address. objective was to make sure she has requisite personal involvement. next steps: either work on letter to senator kyle gay, or go get a cider across the street. put off till tomorrow: pay $1000 5th 3rd credit card bill. just spent 1 hour on hold at 5th 3rd. 2nd time this month. so pissed. never got through to a human.

thursday

took out trash, paid $600 pnc credit card.

next task 5th 3rd.

friday

x saturday: 11:37 covid vaccine riteaid

ups store print off passport stuff for senator young's office. work on letter re passport.

bread, raisins, envelopes.

monday:

did:

called taxi for mom. garage light.

paid $1040 electric bill.

to do

senator young letter re passport. did first draft. tomorrow, print, sign, look for fax machine.

buy a van

pay bill at 5th 3rd if they'll ever answer their phone

what else?

taxes.

clean room and basement.

x groceries/look for that box. envelopes?

to do: file ethics complaint against albence.

same, to county prosecutor

same, to fbi

same, to department of justice

ag's office of naughtiness. might have a form.

cc the governor.

so for tuesday,

1, x dentist

2. clean room and garage

x 3. fax senator young.

5. x 5th 3rd.

x 6. jury questionaire.

x 7. draft letter to delaware legislators re sign case.

posted about it at reddit, had discussions with lawyers and laypeople. 1.0 hours, 10:20 pm.