Fillable Printable Statement of Consent

Statement of Consent

PAPERWORK REDUCTION ACT STATEMENT

DS-3053 08-2013 Page 1 of 2

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

toll-free at 1-877-487-2778 (TDD 1 -888-8 74-779 3) or by e-mail at NP [email protected]. Customer Serv ice Repre sen tatives are availa bl e Mond ay- Frid ay,

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 [email protected].

PRIVACY ACT STATEMENT

1. Complete items 1 and 2.

2. Complete item 3, Statement of Consent, only if you are a non-applying parent or guardian consenting to the issuance of a passport for your minor

child. NOTE: Your signature must be witnessed and notarized in item 4.

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 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, QUESTIONS, AND INQUIRIES

U.S. Department of State

USE OF THIS FORM

The information collected on this form is used in conjunction with the DS-11, "Application for a U.S. Passport". When a minor under age of 16

applies for a passport and one of the minor's parent or legal guard ians is unavailable at the time the passport is executed, a comple ted and

notarized DS-3053 can be used as the statement of consent. If the required statement is not submitted, 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.

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, gathering the necessary data, providing the information and/or documentation 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 Program Management and Operational Support, 2201 C Street NW, Washington, D.C. 20520.

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 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.

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

3. 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

2. MINOR'S DATE OF BIRTH

First Middle

(mm/dd/yyyy)

Last

OATH: I d eclare 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

4. 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: 08-31-2016

ESTIMATED BURD EN : 20 Minute s

DS-3053 08-2013

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 w itnessed 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 Code

StateCity

Telephone Number

E-mail Address

U.S. Depart me nt of State

( )

Area Code

, give my consent to the issuance of a United States passport to

my minor child named on this application.

Print Name (non-applying parent)

Print Name (Notary Public)