*OMB APPROVAL NO. 1405-0169 EXPIRATION DATE: 10/31/2012 ESTIMATED BURDEN: 30 Minutes* U.S. Department of State REQUEST FOR ENTRY INTO CHILDREN'S PASSPORT ISSUANCE ALERT PROGRAM 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. 1. Please provide information about the child in order to make the alert system effective. Please print clearly or type the information. Date of Birth (mm-dd-yyyy) Child's Full Name (Last, First, Middle) Child's Sex 2. U.S. Passport Number (s) , if any Social Security Number Female Place of Birth Male Please provide the following information about yourself so that we can acknowledge your request, and alert you in the future. Documentation of Identity Provided Other Form of Photo Driver's License Identification with Signature Passport Your Full Name (Last, First, Middle) Relationship to Child Shown Above Documentation of Parentage, Guardianship, Legal Custody OR Authority to Act on Behalf of Parent or Legal Guardian, as applicable Birth Certificate Consular Report of Birth Abroad (CRBA) Adoption Current Custody/ Guardianship Court Order(s) Evidence of Authority to Act on Behalf of Parent or Legal Custodian Other Mailing Address City State or Country Postal Code NOTE: 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. Home Phone 3. Work Phone Cell Phone Email Address (es) 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. I object to the Issuance of a U.S. Passport to the Aforementioned Child, but I understand that under prescribed circumstances (see 22 CFR 51.28) the Department is authorized to issue the passport nonetheless. Signature Date (mm-dd-yyyy) 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; 2201 C Street NW, SA-29, Washington, DC 20520; Email: PreventAbduction@state.gov; Telephone Number 1-888-407-4747, Fax Number 202-736-9133. DS-3077 10-2011 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DUAL NATIONALITY FOR CHILDREN 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 addresses and telephone numbers for the embassies and consulates of foreign countries in the United States are listed on the Consular Affairs Internet web page at: >>http://travel.state.gov