Statement Of Consent Or Special Circumstances Issuance Of A Passport To A Minor Under Age 16 Page 2
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2STATEMENT OF CONSENT OR SPECIAL CIRCUMSTANCES:
OMB APPROVAL NO: 1405-0129
ISSUANCE OF A PASSPORT TO A MINOR UNDER AGE 16
EXPIRATION DATE: 12-31-2013
Attention: Read WARNING and FORM INSTRUCTIONS on page 1
ESTIMATED BURDEN: 60 Minutes
1. MINOR'S NAME
Last
First
Middle
2. MINOR'S DATE OF BIRTH
(mm/dd/yyyy)
3. YOUR RELATIONSHIP TO MINOR
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
City, State
SEAL
Commission Expires
Date (mm/dd/yyyy)
Signature of Notary
Driver's License
Passport
Military Identification
Date of
Identification Presented
Notarization
Other (specify)
by Non-Applying Parent or
Date (mm/dd/yyyy)
Guardian:
Issue Date:
Place of Issue:
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
Date (mm/dd/yyyy)
Page 2 of 2
DS-3053 12-2010
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