U.S. Department of State STATEMENT OF EXIGENT/SPECIAL FAMILY CIRCUMSTANCES FOR ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16 USE OF THIS FORM 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. Use this form only if the notarized, written consent of a parent or legal guardian with custody 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 show that there are exigent or special family circumstances that make two parent/guardian consent unobtainable. 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. Your request may qualify as a special family circumstance if the minor's family situation makes it exceptionally difficult or impossible for one or both of the minor's custodial parents/legal guardians to provide the notarized, written consent. 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 U.S. passport application. 2. If you are unsure of the answer to a question, please provide a response to the best of your knowledge. 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. 3. If you have no knowledge of the answer to a question, please write "I don't know." FOR MORE INFORMATION AND/OR QUESTIONS 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 1-888-874-7793) or by e-mail at NPIC@state.gov. Customer Service Representatives are available Monday-Friday, 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 PreventAbduction@state.gov. 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. PRIVACY ACT STATEMENT 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 this information is to establish a possible exigent/special 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. PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time required 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 Program Management and Operational Support, 2201 C Street NW, Washington, D.C. 20520. DS-5525 08-2013 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com U.S. Department of State STATEMENT OF EXIGENT/SPECIAL FAMILY CIRCUMSTANCES FOR ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16 1. Minor's Name (Last, First, Middle) OMB APPROVAL NO: 1405-0216 EXPIRATION DATE: 08-31-2016 ESTIMATED BURDEN: 30 Minutes 2. Minor's Date of Birth (mm/dd/yyyy) 3. Non-Applying Parent/Guardian's Name (Last, First, Middle) Last First Middle 4. Other Names of Non-Applying Parent/Guardian 5. Non-Applying Parent/Guardian's Date of Birth (mm/dd/yyyy) 6. Non-Applying Parent/Guardian's Last Known Contact Information Street City Telephone Number: ( ) State ZIP Code E-mail Address: Apartment No. Country 7. 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.) Yes No If yes, you must provide a complete, signed, and dated copy of the order(s)/decree(s) with this form. 8. Is the non-applying parent/guardian currently incarcerated? (consent from the incarcerated parent/guardian may be required) Yes No If yes, please provide any documentation 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. 9. 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 cannot locate the non-applying parent/guardian, ple