Fillable Printable Statement of Consent or Special Circumstances
Fillable Printable Statement of Consent or Special Circumstances
Statement of Consent or Special Circumstances
AUTHORITIES: Collection of the information solicited on this form is authorized by Titles 8, 22, and 26 of the United States Code,
and other applicable laws and regulations, including 22 USC 211a et seq.; 8 USC 1104; 26 USC 6039E, Section 236 of the Admiral
James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001; Executive Order 11295
(August 5, 1966); and 22 CFR parts 50 and 51.
PURPOSE: The primary purpose for soliciting the information is to establish citizenship, identity, and entitlement to issuance of a
U.S. passport.
ROUTINE USES: The information solicited on this form may be made available as a routine use to other government agencies and
private contractors to assist the U.S. Departmen t of State in adjudicating passport ap plications and requests for related servi ces, and
for law enforcement, fraud prevention, border security, counterterrorism, litigation activities, and administrative purposes. The
information may be mad e available to foreign government agen cies to fulfill passport control and immigra tion 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. citizens and non-citizen nationals abroad. The information may be made available to the Department of
Homeland Security and private employers for employment verification purposes. For a more detailed listing of the routine uses to
which this information may be put see the Department of State's Prefatory Statement of Routine Uses relative to the Privacy Act
(Public Notice 6290 of July 15, 2008) and the listing of routine users set forth in the System of Records Notices for Overseas Citizen
Services Records (Sta te-05) and Passport Records (State-26) published in the Federal Register.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Failure to pr ovide the informati on requested on this form may result
in Passport Services' refusal to accept your application or result in the denial of a U.S. passport.
Public reporting burden fo r this collecti on of information is estimated to average 60 minutes per resp onse, including the time required
for searching existing data sources, gathering the necessary data, providing the information and/or documentation required, and
reviewing the final collecti on. 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 recommenda tions for reducing it, please send th em to:
A/GIS/DIR, Room 2400 SA-22, U.S. Department of State , W ashington, DC 20520-2202.
PAPERWORK REDUCTION ACT STATEMENT
DS-3053 12-2010
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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 1-888-874-7793) or by e-mail at [email protected]
. Customer Service Representatives are available
Monday-Friday, 8:00a.m.-10:00p.m. Eastern Time (excluding federal holidays). Automate d information is availabl e 24/7.
PRIVACY ACT STATEMENT
FORM INSTRUCTIONS
1. Complete items 1, 2, and 3.
2. Complete item 4a, Statement of Consent, onl
y 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 4b.
3. The written consent from the non-applying parent that accompanies an application for a new passport must
not
be more than 3 months old. A photocopy of the front and back side of the non-applying parent's
identification is required with the written consent.
4. Complete item 5, Statement of Special Circumstances, only
if you are an applying parent or guardian and
the written consent of the non-applying parent or guardian cannot be obtained. The statement must explain
in detail
the non-applying parent's unavailability and recent efforts made to contact the non-applying
parent.
STATEMENT OF CONSENT OR SP ECIAL CIRCUMSTANCES:
ISSUANCE OF A PASSPORT TO A MINOR UNDER AGE 16
HOW DO I USE THIS FORM?
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, QUESTI O NS, AND INQUIRI E S
4a. STATEMENT OF CONSENT To be completed by the non-applying paren t or guardian wh en he or she will not be present at
the time th e applying parent or guard ian submits the minor's application. State ment must no
t be more than 3 months old.
1. MINOR'S NAME
2. MINOR'S DATE OF BIRTH 3. YOUR RELATIONSHIP TO MINOR
First Middle
(mm/dd/yyyy)
Last
, give my consent to the issuance of a United States passport to
OATH: I declare under penalty of perjury that all statements made in this supporting document are true and correct.
I,
my minor child named on this application.
Print Your Name
Signature of Parent or Guardian Date (mm/dd/yyyy)
4b. STATEMENT OF CONSENT NOTARIZATION
Name of Notary
Print Name
Location
City, State
Commission Expires
Dat e (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 Identification
Drive r 's Lic e ns e
Other (specify)
Issue Date:
Place of Issue:
ID Number:
STATEMENT OF CONSENT OR SPECIAL CIRCUMSTANCES:
ISSUANCE OF A PASSPORT TO A MINOR UNDER AGE 16
OMB APPRO VAL NO : 1405-0129
EXPIRATION DATE: 12-31-2013
ESTIMATED BURDEN: 60 Minutes
DS-3053 12-2010
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Attention: Read WARNING and FORM INSTRUCTIONS on page 1
Date (mm/dd/yyyy)
Signature of Parent or Guardian
OATH: I declare under penalty of perjury that all statements made in this supporting document are true and correct.
5. STATEMENT OF SPECIAL CIRCUMSTANCES To be completed by applying parent or guardian when the written consent of
the non-applying parent or guardian cannot be obtained. The statement must explain in detail
the non-applying parent's unavailability
and recent efforts made to contact the non-applying parent. Attach additional pages if needed.
