Statement Of Exigent/special Family Circumstances For Issuance Of A U.s. Passport To A Minor Under Age 16 Page 2
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2U.S. Department of State
OMB CONTROL NO. 1405-0216
OMB EXPIRATION DATE: 08-31-2019
STATEMENT OF EXIGENT/SPECIAL FAMILY CIRCUMSTANCES
ESTIMATED BURDEN: 30 Minutes
FOR ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16
1. Minor's Name (Last, First, Middle)
2. Minor's Date of Birth (mm/dd/yyyy)
3. Applying Parent/Guardian's Name (Last, First, Middle)
4. Non-Applying Parent/Guardian's Information
Last Name
First & Middle Name
Date of Birth (mm/dd/yyyy)
Other Names They May Have Used
Street
Apartment No.
City
State
ZIP Code
Country
E-mail Address:
Telephone Number: (
)
5. 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 submit a complete, signed, and dated copy of the most recent order(s)/decree(s) with this form.
6. Is the non-applying parent/guardian currently incarcerated?
Yes
No
If yes, submit evidence of incarceration 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.
7. Describe your attempts to contact the Non-Applying Parent.
(If you need more space, continue on a separate paper.)
By Mail Number of times:
Approximate Dates:
Result:
Phone
Number of times:
Approximate Dates:
Result:
E-mail
Number of times:
Approximate Dates:
Result:
Social
Number of times:
Approximate Dates:
Result:
Media
Other
Have you attempted to contact through a friend or relative? If so, please fill out the information below.
Name:
How they know the non-applying parent:
Ex: John Smith
Ex: Works with Non-Applying Parent
Address:
Street
City
State or Country
Approximate Dates:
Result:
Phone:
Name:
How they know the non-applying parent:
Ex: John Smith
Ex: Works with Non-Applying Parent
Address:
Street
State or Country
City
Approximate Dates:
Result:
Phone:
8. 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 need more space, please continue on a separate paper.)
OATH: I declare under penalty of perjury that all statements made in this supporting document are true and correct.
Signature of Parent
or Legal Guardian:
Date
:
(mm/dd/yyyy)
DS-5525 08-2016
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