DS-3013 Application under the Hague Convention on Civil Aspects

U. S. Department of State

APPLICATION UNDER THE HAGUE CONVENTION ON THE CIVIL
ASPECTS OF INTERNATIONAL CHILD ABDUCTION

OMB NO. 1405-0076
EXPIRES 10-31-2009
Estimated Burden - 1 Hour*

FILL OUT ALL SECTIONS ON BOTH SIDES
*Provide Information Below to the extent that it is available.

This is an application for the

Return

Access to the child/ren listed.

I. FIRST CHILD SUBJECT OF APPLICATION
Date of Birth (mm-dd-yyyy)

Child's Name (Last, First, MI.)

U.S. SSN*

Address (At Time of Removal)

Place of Birth

Passport/Identity Card*
Country
Number
Citizenship (s)

Address and Telephone Number of Child's Current Location (If Known)

Weight

Height

Name of Child's Father if not Listed in Section II or III.

Color of Hair

Color of Eyes

Name of Child's Mother if not Listed in Section II or III.

II. APPLICANT (PERSON SEEKING RETURN OF/ACCESS TO CHILD/REN)
Name (Last, First, MI)

Relationship to Child/ren

Citizenship(s)

Date of Birth (mm-dd-yyyy)

Place of Birth

U.S. SSN*

Passport/Identity Card*
Country
Number
Occupation

Current Address, Telephone, Number, and Email Address

Name, Address, and Telephone Number or Legal Advisor*

III. PERSON ALLEGED TO HAVE WRONGFULLY REMOVED OR RETAINED THE CHILD/REN
Date of Birth (mm-dd-yyyy)

Name (Last, First, MI)

Relationship to Child/ren

Citizenship(s)

U.S. SSN*

Place of Birth

Passport/Identity Card*
Country
Number
Known Aliases

Occupation, Name, and Address of Employer (If Known)

Address and Telephone Number of Current Location

Height

DS-3013
02-2007

Weight

Color of Hair

Color of Eyes

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IV. ADDITIONAL CHILD/REN Subject of Application
Child's Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Address (At Time of Removal)

U.S. SSN*

Place of Birth

Passport/Identity Card*
Country
Number

Citizenship(s)

Address and Telephone Number of Child's Location (If Known)

Height

Weight

Color of Eyes

Color of Hair

Name of Child's Father if not Listed in Section II or III.

Name of Child's Mother if not Listed in Section II or III.

Child's Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Place of Birth

Address (At Time of Removal)

U.S. SSN*

Passport/Identity Card*
Country
Number

Citizenship(s)

Address and Telephone Number of Child's Current Location (If Known)

Height

Weight

Color of Eyes

Color of Hair

Name of Child's Father if not Listed in Section II or III.

Name of Child's Mother if not Listed in Section II or III.

Child's Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Address (At Time of Removal)

U.S. SSN*

Place of Birth

Passport/Identity Card*
Country
Number

Address and Telephone Number of Current Location (If Known)

Height

Weight

Citizenship(s)

Color of Hair

Color of Eyes

Name of Child's Father if not Listed in Section II or III.

Name of Child's Mother if not Listed in Section II or III.

Child's Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Address (At Time of Removal)

U.S. SSN*

Place of Birth

Passport/Identity Card*
Country
Number

Citizenship(s)

Address and Telephone Number of Current Location (If Known)

Height

Weight

Name of Child's Father if not Listed in Section II or III.

DS-3013

Color of Hair

Color of Eyes

Name of Child's Mother if not Listed in Section II or III.

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ADDITIONAL SHEETS MAY BE ATTACHED

V. TIME, PLACE, DATE AND CIRCUMSTANCES OF THE WRONGFUL REMOVAL OR RETENTION
Additional sheets may be attached.

VI. FACTUAL AND LEGAL JUSTIFICATION FOR THE REQUEST
Habitual Residence (Please provide details related to the child's place of habitual residence.)

Basis of Applicants's Custody Rights
Supporting Documentation (Please check applicable boxes and attach.)
Law/Statute of Child's Residence at Time of Alleged Removal or Retention
Court Order in Effect at Time of Alleged Removal or Retention
Legally Binding Agreement
Marriage Certificate, If Applicable
Child's Birth Certificate, Required
Other
Are civil proceedings currently in progress? (If yes, please provide details.)

DS-3013

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ADDITIONAL SHEETS MAY BE ATTACHED

VII. PROPOSED ARRANGEMENTS FOR RETURN TRAVEL OF CHILD

VIII. OTHER PERSONS WITH ADDITIONAL INFORMATION RELATING
TO THE WHEREABOUTS OF THE CHILDREN
Preferably, in country of child's current location. Please include, name, address, telephone number, and /or email address.

IX. OTHER RELEVANT INFORMATION

Signature of Applicant (Sign in Blue Ink)

Date (mm-dd-yyyy)

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS
This information solicited on this form is requested under the authority of the International Child Abduction Remedies Act, Public Law 100-300. The primary purpose for soliciting
the information is to evaluate applicants' claims under the Hague Convention on the Civil Aspects of International Child Abduction, advise applicants about available legal
remedies, and locate abducted children. The principal users of this information are offices within the U.S. Department of State's Bureau of Consular Affairs. The information will
be used to assist in facilitating operations under the Convention and may be provided to governments of member countries, bar associations and legal aid services, local police,
social service agencies, and parents. This information may also be released on a need-to-know basis to other government agencies, including foreign agencies, having
statutory or other lawful authority to gain access to such information. Furnishing your social security number, as well as the other information requested on this form, is
voluntary. However, failure to submit this form or to provide all the requested information may result in delay in the processing of your application.
*Public reporting burden for this collection of information is estimated to average1hour per response, including time required for searching existing data sources, gathering the
necessary data, providing the information required, and reviewing the final collection. You do not have to provide this information requested if the OMB approval has expired.
Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State (A/ISS/DIR), 1800 G Street, Washington, DC
20520.

DS-3013

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