Issuance Of A Passport To A Minor (Under Age Of 16)
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2U.S. Department of State
OMB APPROVAL NO: 1405-0129
EXPIRATION DATE: 12-31-2010
STATEMENT OF CONSENT OR SPECIAL CIRCUMSTANCES:
ESTIMATED BURDEN: 60 Minutes
ISSUANCE OF A PASSPORT TO A MINOR UNDER AGE 16
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 the provisions
of 18 U.S.C. 1001, 18 U.S.C. 1542, and/or 18 U.S.C. 1621.
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. 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.
1.
MINOR’S NAME
Last
First
Middle
2.
MINOR’S DATE OF BIRTH
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.
I, ______________________________________, give my consent to the issuance of a United States passport to my minor child
Print Your Name
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
NOTARY
Location
SEAL
City, State
Commission Expires
Date (mm/dd/yyyy)
Signature of Notary
Driver’s License
Passport
Military Identification
Date of
Identification Presented
Other (specify)
by Non-Applying Parent or
Notarization
Place of Issue
Issue Date
Guardian:
Date (mm/dd/yyyy)
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.
(Use back of form if additional space is 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
Date (mm/dd/yyyy)
DS-3053
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02-2008
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