Fillable Printable Form DS-3053

Form DS-3053

The information collected on this form is used in conjun ction with the DS-11, "Application for a U.S. Passport." When a m inor under the age

of 16 applies for a passport and one of the minor's parents or legal guardians is unavailable at the time the passport is executed, a completed

and notarized DS-3053 can be used as th e statement of consent. If the required sta tement is not s ubmitted, the minor may not be eligible to

receive a U.S. passport. The required statement may be submitted in other formats provided they meet statutory and regulatory

requirements.

USE OF THIS FORM

DS-3053 08-2016 Page 1 of 2

For passport and travel in formation, please v i sit o ur website at travel.state.gov. In addition, contact the National Passpo rt Information C enter (N PIC )

toll-free at 1-877-487-2778 (TDD 1-888-874-7793) or by e-mail at [email protected]ov

. Customer Service Representatives are available

Monday-Friday, 8:00 a.m. - 10:00 p.m. Eastern Standard Time (excluding federal holidays). Automated information is available 24/7.

For information on International Parental Child Abduction, please visit www.travel.state.gov/childabduction

or contact the Office of Children's

Issues by telephone at 1-888-407-4747 or by e-mail at PreventAbd[email protected]

1. Complete fields 1, 2, and 3. If field 3 is not completed, authorization will be valid for both products.

2. Complete field 4, Statement of Consent, only if you are a non-applying parent or guard ian consenting to the issuan ce of a passport for your minor

child. NOTE: Your signature must be witnessed and notarized in field 5.

3. The written consent from the non-applying parent that accompanies an application for a new U.S. passport must not be more than 90 days old.

A clear photocopy of the front and back of the non-applying parent's government-issued photo identification presented to the notary is required

with the written consent.

4. Please submit this form with your minor child's new DS-11 passport application to any designated acceptance facility, U.S. Passport Agency, U.S.

Embassy, or U.S. Consulate abroad.

STATEMENT OF CONSENT:

ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16

FORM INSTRUCTIONS

WARNING: False statements made knowingly and willfully on passport applications, including affidavits or other supporting documents

submitted therewith, may be punishable by fine and/or imprisonment under U.S. law, including the provisions of 18 U.S.C. 1001, 18 U.S.C.

1542, and/or 18 U.S.C. 1621.

FOR INFORMATION AND QUESTIONS

U.S. Department of State

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time required for searching

existing data sources, ga thering 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 displa ys a currently valid OMB co ntrol numbe r. If yo u hav e 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, Attn: Forms Officer 44132 Mercure Cir, P.O. Box 1227, Sterling, Virginia 20166-1227.

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: The primary purpose for soliciting the information is to establish two parent consent for a minor's passport application, as required by

Public Law 106-113, Section 236.

ROUTINE USES: This information may be disclosed to another domestic government agency, a private contractor, a foreign government agen c y, or t o

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: Failure to provide the information requested on this form may result in the refusal or denial of a U.S. passport application.

Below is a list of documents you must submit with your DS-3053:

1. A c

ertified order of a court of competent jurisdiction granting guardianship to the institution/entity. (Photocopies are not acceptable.)

2. A signed statement from the institution/entity on letterhead authorizing a specific person to apply for a passport for the child on its behalf. The

statement must include the minor's name and the name of the individual(s) authorized to apply for the passport.

3. A photocopy of employee identification documents proving the person applying for the minor's passport works at the institution/entity.

SPECIAL REQUIREMENTS FOR INSTITUTIONS/ENTITIES GRANTED GUARDIANSHIP

PAPERWORK REDUCTION ACT STATEMENT

PRIVACY ACT STATEMENT

Please ensure that all of the above do NOT have any conditions placed on the period of validity of the passport or where the minor may travel. If there

are conditions in the statement, a new statement of unequivocal consent is required.

Passport Boo k an d Ca rd

3. THIS AUTHORIZATION IS VALID FOR:

to apply for a United States passport for my minor child named on this application. My consent is unconditional in regards to passport validity and travel.

STOP! YOU MUST SIGN THIS FORM IN FRONT OF A NOTARY.

2. MINOR'S DATE OF BIRTH

First Middle

(mm/dd/yyyy)

Last

4. STATEMENT OF CONSENT To be completed by the non-applying parent or guardian using his/her information when not

present at the time the applying parent or guardian submits the minor's application. Statements expire after 90 days.

1. MINOR'S NAME

OATH: I declare under penalty of perjury that all statements made in this supporting document are true and correct.

Date (mm/dd/yyyy)Signature of Non-Applying Parent or Guardian

5. STATEMENT OF CONSENT NOTARIZATION

Name of Notary

Location

City, State

Commission Expires

Date (mm/dd/yyyy)

Signature of Notary

NOTARY

SEAL

Date of

Notarization

Date (mm/dd/yyyy)

Identification Presented

by Non-Applying Parent or

Guardian:

Passport Military IDDriver's License Other (specify)

Issue Date (mm/dd/yyyy):

Place of Issue:ID Number:

STATEMENT OF CONSENT:

ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16

OMB CONTROL NO. 1405-0129

OMB EXPIRATION DATE: 08-31-2019

ESTIMATED BURD EN : 20 Minute s

DS-3053 08-2016

Page 2 of 2

Attention: Read WARNING and FORM INSTRUCTIONS on Page 1

NOTE

: A clear photocopy of the front and back of the identification you presented to the notary is required with this form.

Expiration Date (mm/dd/yyyy):

OATH: By signing this document, I certify that I am a licensed notary under laws and regulations of the state or country for which I am

performing my notarial duties, that I am not related to the above affiant, that I have personally witnessed him/her sign this document, and

that I have properly verified the identity of the affiant by personally viewing the above notated identification document and the matching

photocopy.

Street Address (non-applying parent)

Apartment Zip CodeStateCity

Telephone Number E-mail Address

U.S. Depart me nt of State

( )

Area Code

Print Name (non-applying parent/guardian)

Print Name (Notary Public)

authorize

Print Name (person applying for minor's passport)

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