Fillable Printable Form DS-5525

Form DS-5525

USE OF THIS FORM

FORM INSTRUCTIONS

1. Please complete the questions on this form to the best of your knowledge. Generally, the more information you are able to provide, the

faster we may be able to process your minor child's U.S. passport application. For example, if you are unsure of an exact address, please provide the

city, state, or street name if you can recall them. Passport Services will consider all the information derived from the form in its entirety.

2. If you need more space to respond to a question, please write the rest of your response on a separate sheet of paper.

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.

Passport applications for minors under the age of 16 require both custodial parents/legal guardians' signatures unless a notarized, written

statement of consent from the non-applying custodial parent/legal guardian is provided.

If you have a current court order reflecting full/sole custody or granting permission to obtain a passport, it is likely you will not need to

fill out this form. Court orders must be submitted with the minor's passport application.

Use this form only if the notarized, writte n consent of a parent or legal guardian w ith custod y of the minor applicant under 16 cannot be

obtained. Your statement in the form must explain the reason why you cannot obtain the notarized statement of consent. You must justify that

there are exigent or special family circumstances that make two parent/guardian consent unobtainable. Please note completion of this form does

not guarantee passport issuance.

Your request may qualify as a exigent circumstance if there is a time-sensitive emergency and the inability of the minor to obtain a passport would

jeopardize the minor's health or welfare and safety or welfare of the minor or would result in the minor being separ ated from the rest of his or her

traveling party.

Your request may qualify as a specia l family circumstance if the minor's family situation makes it exceptionally difficult or impossible for one o r both

of the minor's custodial parents/legal guardians to provide the notarized, written consent.

FOR MORE INFORMATION AND/OR QUESTIONS

For passport and travel information, please visit our website at travel.state.gov. In addition, contact the Nationa l Passport Information Center (NPIC)

toll-free at 1-877-487-2778 (T DD 1- 888-87 4-7793 ) or by e-mail at NP IC @s tat e.g ov

. Customer Service Representatives are ava ilable Mon day-Fr iday,

8:00a.m.-10:00p.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 [email protected]

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 solicit ing this inf ormation is to establish a pos sible exigent/spec ial family circumstance exception to Public Law

106-113, Section 236, requiring two parent consent for a minor's passport application.

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

PRIVACY ACT STATEMENT

WARNING

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time requir ed for searching

existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection.

Responding to this collection of information is required to obtain a benefit. 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, Attn:

Forms Officer, 44132 Mercure Cir, P.O. Box 1227, Sterling, Virginia 20166-1227.

DS-5525 08-2016 Page 1 of 2

U.S. Department of State

STATEMENT OF EXIGENT/SPECIAL FAMILY CIRCUMSTANCES

FOR ISSUANCE OF A U.S. PASSPORT TO A MIN OR UNDER AGE 16

8. Please explain in detail the reason for your request to issue a U.S. passport book and/or card without the

non-applying parent/guardian's consent.

(If you need more space, please continue on a separate paper.)

CityStreet

Ex: Works with Non-Applying Parent Ex: John Smith

Have you attempted to contact through a friend or relative? If so, please fill out the information below.

7. Describe your attempts to contact the Non-Applying Parent. (If you need more space, continue on a separate paper.)

By Mail Number of times: Approximate Dates: Result:

Phone Number of time s: Approximate Date s: Result:

E-mail Number of time s: Approximate Date s: Result:

Social

Media

Number of time s: Approximate Date s: Result:

Other

Name:

How they know the non-applying parent:

Phone:

Address:

State or Country

Approximate Dates: Result:

5. Has any court, either in the United States or abroad, ever issued an order/decree that references the custody

or travel of the minor child in question? (Examples include a divorce decree, custody order, protection order,

stay away order, restraining order, etc.)

NoYes

If yes, you must submit a complete, signed, and dated copy of the most recent order(s)/decree(s) with this form.

6. Is the non-applying parent/guardian currently incarcerated?

Yes No

If yes, submit evidence of incarceration with this form, such as a letter from the convicting criminal court, a copy of the incarceration

court order, or a copy of the on-line inmate locator page.

Signature of Parent

or Legal Guardian: Date

(mm/dd/yyyy):

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

3. Applying Parent/ Guardia n's Name (Last, First, Middle)

City

ZIP Code

State

Apartment No.

Street

Telephone Number: ( )

E-mail Address:

STATEMENT OF EXIGENT/SPECIAL FAMILY CIRCUMSTANCES

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

DS-5525 08-2016 Page 2 of 2

2. Minor's Date of Birth (mm/dd/yyyy)1. Minor's Name (Last, First, Middle)

OMB CONTROL NO. 1405-0216

OMB EXPIRATION DATE: 08-31-2019

ESTIMATED BURDEN: 30 Minutes

U.S. Department of State

Country

Date of Birth (mm/dd/yyyy)

4. Non-Applying Parent/Guardian's Information

Last Name

Other Names They May Have Used

First & Middle Name