STATEMENT OF CONSENT OR SPECIAL CIRCUMSTANCES: ISSUANCE OF A PASSPORT TO A MINOR UNDER AGE 16 HOW DO I USE THIS FORM? FORM INSTRUCTIONS 1. Complete items 1, 2, and 3. 2. Complete item 4a, 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 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. 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 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 NPIC@state.gov. Customer Service Representatives are available Monday-Friday, 8:00a.m.-10:00p.m. Eastern Time (excluding federal holidays). Automated information is available 24/7. PRIVACY ACT STATEMENT 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. Department of State in adjudicating passport applications and requests for related services, and for law enforcement, fraud prevention, border security, counterterrorism, litigation activities, and administrative purposes. 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. 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 (State-05) and Passport Records (State-26) published in the Federal Register. CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Failure to provide the information requested on this form may result in Passport Services' refusal to accept your application or result in the denial of a U.S. passport. PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is estimated to average 60 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: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20520-2202. DS-3053 12-2010 Page 1 of 2 STATEMENT OF CONSENT OR SPECIAL CIRCUMSTANCES: ISSUANCE OF A PASSPORT TO A MINOR UNDER AGE 16 OMB APPROVAL NO: 1405-0129 EXPIRATION DATE: 12-31-2013 ESTIMATED BURDEN: 60 Minutes Attention: Read WARNING and FORM INSTRUCTIONS on page 1 1. MINOR'S NAME Last First 2. MINOR'S DATE OF BIRTH Middle 3. YOUR RELATIONSHIP TO MINOR (mm/dd/yyyy) 4a. STATEMENT OF CONSENT To be completed by the non-applying parent or guardian when he or she will not be present at the time the applying parent or guardian submits the minor's application. Statement must not be more than 3 months old. I, , give my consent to the issuance of a United States passport to Print Your Name my minor child named on this application. OATH: I declare under penalty of perjury that all statements made in this supporting document are true and correct. Signature of Parent or Guardian Date (mm/dd/yyyy) 4b. STATEMENT OF CONSENT NOTARIZATION Name of Notary Print Name Location NOTARY SEAL City, State Commission Expires Date (mm/dd/yyyy) Signature of Notary Driver's License Date of Notarization Date (mm/dd/yyyy) Identification Presented by Non-Applying Parent or Guardian: Passport Military Identification Other (specify) Place of Issue: Issue Date: ID Number: 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. OATH: I declare under penalty of perjury that all statements made in this supporting document are true and correct. Signature of Parent or Guardian DS-3053 12-2010 Date (mm/dd/yyyy) Page 2 of 2