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I would like to receive a certified copy of my recent application for a passport. Again, I am NOT seeking a certified
copy of my passport but rather the application that I submitted to receive the passport. The application was
submitted with an Explanatory Statement Annexed to the application. Please understand that the word Annex is
a lawful definition meaning to permanently affix to. I am requesting that the Annexed Explanatory Statement be
certified and sent back with the original DS-11 form. Time on insert date and they gave me the following
information that I would have to submit to receive this certified copy. They were unsure as to the fees, so they
told me to pay the $50.00 and leave you with my phone number to contact in case there was more money
required. Reason: For my records purposes.
Thank you,
By: ____________________________________
Non Assmupsit, A.R.R., w/o Prejudice
ALL-PURPOSE ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity of the individual who signed
the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of this document.
State of California )
) For Verification Purposes Only
______________ County )
I certify under PENALTY OF PURJURY under the laws of the State of California that the foregoing paragraph is true
and correct. WITNESS my hand and official seal.
Signature ___________________________________________