Child's Full Name
REQUEST FORM An alert request may be filed with respect to an unmarried child under the age of 18. This request
can be filed by concerned parents of U.S. citizen children, their appointed agents, or other persons having legal custody
of the child. Complete one form for each child, and submit the completed request along with proper documents to
Passport Services by e-mail, fax or mail. By signing this form you are affirming that your parental rights to this child have
not been terminated by court order.
Please provide information about the child in order to make the alert system effective. Please print clearly or type
Please provide the following information about yourself so that we can acknowledge your request, and alert you
in the future.
Your Full Name
Relationship to Child
Since the Department will need to contact you, it is very important that you keep us informed in writing or by
telephone of any changes to your contact information. Failure to notify this office of your correct address and
phone number may result in passport issuance for your child without your knowledge.
REQUEST FOR ENTRY INTO
CHILDREN'S PASSPORT ISSUANCE ALERT PROGRAM
U.S. Department of State
Page 1 of 2
*OMB APPROVAL NO. 1405-0169
EXPIRATION DATE: 02-28-2019
ESTIMATED BURDEN: 30 Minutes*
(Last, First, Middle)
Date of Birth
Place of Birth
U.S. Passport Number , if any
Documentation of Identity Provided
Social Security Number
(Last, First, Middle)
Other Form of Photo
Documentation of Parentage, Guardianship, Legal Custody OR Authority to Act on Behalf of Parent or Legal Guardian, as
Consular Report of Birth Abroad
Evidence of Authority to Act on
Behalf of Parent or Legal Custodian
City State or Country Postal Code
Work Phone Cell Phone Email Address
Please read the Dual Nationality for Children information accompanying this form. It relates to a child who may have a foreign nationality in addition
to U.S. nationality.
Please submit via e-mail, fax, or mail the completed form along with the proper copies of the original documents to the U.S. Department of State,
Overseas Citizen Services, Children's Issues; Attention: Children's Passport Issuance Alert Program; SA-17, 9th Floor, Washington, DC
20522-1707; Email: [email protected]; Telephone Number 1-888-407-4747, Fax Number 202-485-6222.
I object to the Issuance of a U.S. Passport to the Aforementioned Child, but I understand that under
prescribed circumstances the Department is authorized to issue the passport
(see 22 CFR 51.28)
I request that the U.S. Department of State notify me if it receives a U.S. passport application for the
above-mentioned child, or if an application is currently pending, or if there is any U.S. passport still valid for
the child's travel.
DUAL NATIONALITY FOR CHILDREN
Page 2 of 2
PRIVACY ACT STATEMENT
AUTHORITY: The information solicited on this form is requested pursuant to provisions in Titles 8 and 22
of the U.S. Code, as well as the corresponding federal regulations, including specifically 22 U.S.C. § 211a
and Public Law 106-113, Div. B, §1000(a)(7) [Div. A., Title II, §236] of the Admiral James W. Nance and Meg
Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001 and Executive Order 11295 (Aug.
5, 1966), and the regulations contained in 22 C.F.R. § 51.28.
PURPOSE: The primary purpose for soliciting the information is to enable the U.S. Department of State to
notify you of any pending U.S. passport applications for the child identified on the form and of any U.S.
passport held by the child that is still valid for travel. The child's social security number is requested
because that number is a unique identifier used to establish the identity of the passport holder.
ROUTINE USES: The information solicited on this form may be made available as a routine use to other
government agencies, to assist the U.S. Department of State in adjudicating passport applications and
requests for related services, and for law enforcement and administrative purposes. It may also be
disclosed pursuant to court order. The information may be made available to foreign government agencies
to fulfill passport control and immigration duties. The information may also be provided to foreign
government agencies, international organizations and, in limited cases, private persons and organizations
to investigate, prosecute, or otherwise address potential violations of law or to further the Secretary's
responsibility for the protection of U.S. nationals abroad. This would include, among other entities and
agencies, disclosure to The National Center for Missing and Exploited Children, Central Authorities of
countries party to the Hague Convention on the Civil Aspects of International Child Abduction ("the
Convention"), attorneys of record and legal aid services to assist in facilitating operations under the
Convention; local police in connection with notification of next-of-kin and child custody disputes; social
services agencies; and parents involved in cases brought under the Convention. The information may also
be made available to private U.S. citizen 'wardens' designated by U.S. embassies and consulates. For a
more detailed listing of the routine uses to which this information may be put, see the Prefatory Statement
of Routine Uses and the listing of routine user set forth in the System of Records Notice (SORN) for
Overseas Citizens Services Records (State-05)., found at: http://www.state.gov/m/a/ips/c25533.htm
DISCLOSURE: Filing a request through the Children's Passport Issuance Alert Program and providing the
information requested on this form, including the child's social security number, is voluntary. Failure to
complete the form may result in a passport being issued to your child without your knowledge.
Many children, born in the U.S. or born abroad to a U.S. citizen parent, are citizens of both the U.S. and another country. A child may acquire the
citizenship of a foreign country, for example, through the child's birth abroad, or through a parent. There is no requirement that a U.S. citizen
parent consent to a child's acquisition of another nationality. Even though U.S. law may prevent one parent from obtaining a U.S. passport for a
child (for example, because of the two-parent signature requirement), a parent may still be able to obtain a foreign passport for a dual national
child from the embassy or government of the other country. Under U.S. law, a United States citizen child is required to enter and depart the United
States on his or her United States passport. However, please be advised that, since there are currently no exit controls from the United States,
U.S. citizen children can still exit the United States undetected on foreign passports.
U.S. law and regulations concerning the issuance of U.S. passports do not apply to foreign governments when they issue passports to people
(including children) whom they consider to be citizens of their country, whether or not the foreign passport is issued in the United States and/or to
a person the United States considers to be a U.S. citizen. If you think there is a possibility that your child may have another nationality, you are
encouraged to contact the relevant country's embassy or consulate directly to inquire about the rules governing the issuance of that country's
passport to your child, including the possible availability of mechanisms to prevent the issuance to your child of that country's passport without
your consent. The address and telephone numbers for the embassies and consulates for foreign countries within the United States can be found
on the Consular Affairs web page at >>travel.state.gov<< under each foreign country's Country Specific Information.
Public reporting burden for this collection of information is estimated to average 30 minutes per response,
including time required for searching existing data sources, gathering the necessary documentation,
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, CA/OCS/L, 10th Floor, WASHINGTON, DC 20522-1707.
PAPERWORK REDUCTION ACT STATEMENT