Ds-3053 - Issuance Of A U.s. Passport To A Minor Under Age 16 Page 2
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2OMB CONTROL NO. 1405-0129
U.S. Department of State
OMB EXPIRATION DATE: 08-31-2016
ESTIMATED BURDEN: 20 Minutes
STATEMENT OF CONSENT:
ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16
Attention: Read WARNING and FORM INSTRUCTIONS on page 1
1. MINOR'S NAME
Last
First
Middle
(mm/dd/yyyy)
2. MINOR'S DATE OF BIRTH
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.
I,
, give my consent to the issuance of a United States passport to
Print Name (non-applying parent)
my minor child named on this application.
Street Address (non-applying parent)
Apartment
City
State
Zip Code
(
)
Area Code
Telephone Number
E-mail Address
STOP! YOU MUST SIGN THIS FORM IN FRONT OF A NOTARY.
OATH: I declare under penalty of perjury that all statements made in this supporting document are true and correct.
Signature of Non-Applying Parent or Guardian
Date (mm/dd/yyyy)
NOTE: A clear photocopy of the front and back of the identification you presented to the notary is required with this form.
4. STATEMENT OF CONSENT NOTARIZATION
Name of Notary
Print Name (Notary Public)
Location
City, State
NOTARY
SEAL
Commission Expires
Date (mm/dd/yyyy)
Identification Presented
Driver's License
Passport
Military ID
Other (specify)
by Non-Applying Parent or
Guardian:
ID Number:
Place of Issue:
Issue Date (mm/dd/yyyy):
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 witnessed 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.
Date of
Signature of Notary
Notarization
Date (mm/dd/yyyy)
DS-3053 08-2013
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