DS-3053 Statement of Consent or Special Circumstances: Issuance

OMB APPROVAL NO: 1405-0129
EXPIRATION DATE: XX-XX-XXXX
ESTIMATED BURDEN: 60 Minutes

U.S. Department of State

STATEMENT OF CONSENT OR SPECIAL CIRCUMSTANCES:
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.
2.

Complete items 1, 2, and 3.
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.
Complete item 5, Statement of Special Circumstances, only if you are an applying parent or guardian and the written consent of the nonapplying parent or guardian cannot be obtained.

3.

1. MINOR’S NAME
Last

2.

First

MINOR’S DATE OF BIRTH

(mm/dd/yyyy)

Middle

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.

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
SEAL

Location
City, State

Commission Expires
Date (mm/dd/yyyy)

Signature of Notary
Driver’s License

Date of
Notarization
Date (mm/dd/yyyy)

Identification Presented
by Non-Applying Parent or
Guardian:

Passport

Military Identifcation

Other (specify)
Place of Issue

Issue Date

ID Number

5. STATEMENT OF SPECIAL CIRCUMSTANCES
consent of the non-applying parent or guardian cannot be obtained.

To be completed by applying parent or guardian when the written

(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
DS-3053
XX-XXXX

Date (mm/dd/yyyy)
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CONTINUATION OF STATEMENT OF SPECIAL CIRCUMSTANCES:

FOR INFORMATION, QUESTIONS, AND INQUIRIES:
Please visit our website at travel.state.gov. In addition, contact the National Passport Information Center (NPIC) toll-free
at 1-877-487-2778 (TDD: 1-888-874-7793) or by e-mail at [email protected]. Customer Service Representatives are
available M-F, 6AM-12AM ET (excluding Federal holidays). Hours and days may be extended in relation to call
volume. Automated information is available 24/7.
PRIVACY ACT STATEMENT
AUTHORITIES: The information solicited on this form is requested pursuant to 22 U.S.C. 211a, 212, 213, and Section 236 of the
Admiral James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and 2001; Executive Order 11295
(August 5, 1966); and 22 CFR 51.28.
PURPOSE: The primary purpose is to document the notarized written consent of a parent or legal guardian to the issuance of a U.S.
passport to a child under fourteen years of age, or, alternatively, to document the existence of exigent or special family circumstances, when
the parent or legal guardian is not present when an application is made for issuance of a U.S. passport for the child.
ROUTINE USES: The information solicited on this form may be made available as a routine use to other government agencies to assist
the U.S. Department of State in adjudicating passport applications and requests for related services, and for law enforcement and
administrative purposes. The information may be made available to foreign government agencies to fulfill passport control and immigration
duties. The information may also be provided to foreign government agencies, international organizations and, in limited cases, private
persons and organizations to investigate, prosecute, or otherwise address potential violations of law or to further the Secretary’s
responsibility for the protection of U.S. citizens and non-citizen nationals abroad. The information may be made available to private U.S.
citizen ‘wardens’ designated by the U.S. embassies and consulates. For a more detailed listing of the routine uses to which this information
may be put, see the Prefatory Statement of Routine Uses and the listing of routine users set forth in the system descriptions for Overseas
Citizen Services Records (State-05) and Passport Records (State-26) published in the Federal Register.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: You are not legally required to provide the information requested
on this form. However, failure to do so may result in Passport Services’ refusal to accept your application or result in the denial of a U.S.
passport.

PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 60 minutes 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 the information unless this collection displays a currently valid OMB number. 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) Washington DC 20520.

DS-3053

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