Form DS-3053 Statement of Consent: Issuance of a U.S. Passport to a M

U.S. Department of State
STATEMENT OF CONSENT:
ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16

USE OF THIS FORM
The information collected on this form is used in conjunction with the DS-11, "Application for a U.S. Passport". When a minor under
age of 16 applies for a passport and one of the minor's parent or legal guardians is unavailable at the time the passport is executed, a
completed and notarized DS-3053 can be used as the statement of consent. If the required statement is not submitted, the minor may
not be eligible to receive a U.S. passport. The required statement may be submitted in other formats provided they meet statutory and
regulatory requirements.

FORM INSTRUCTIONS
1. Complete items 1 and 2.
2. Complete item 3, 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 4.
3. The written consent from the non-applying parent that accompanies an application for a new U.S. passport must not be more than
90 days old. A clear photocopy of the front and back of the non-applying parent's government-issued photo identification is
required with the written consent.
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 U.S. law, including the
provisions of 18 U.S.C. 1001, 18 U.S.C. 1542, and/or 18 U.S.C. 1621.

FOR INFORMATION, QUESTIONS, AND INQUIRIES
For passport and travel information, 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 Monday-Friday, 8:00a.m.-10:00p.m. Eastern Standard Time (excluding federal holidays). Automated
information is available 24/7.
For information on International Parental Child Abduction, please visit www.travel.state.gov/childabduction or contact the Office of
Children's Issues by telephone at 1-888-407-4747 or by e-mail at [email protected].

PRIVACY ACT STATEMENT
AUTHORITIES: We are authorized to collect this information by 22 U.S.C. 211a et seq.; 8 U.S.C. 1104; 26 U.S.C. 6039E; Executive
Order 11295 (August 5, 1966); and 22 C.F.R. parts 50 and 51.
PURPOSE: The primary purpose for soliciting the information is to establish two parent consent for a minor's passport application, as
required by Public Law 106-113, Section 236.
ROUTINE USES: This information may be disclosed to another domestic government agency, a private contractor, a foreign
government agency, or to a private person or private employer in accordance with certain approved routine uses. These routine uses
include, but are not limited to, law enforcement activities, employment verification, fraud prevention, border security, counterterrorism,
litigation activities, and activities that meet the Secretary of State's responsibility to protect U.S. citizens and non-citizen nationals
abroad.
More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas Citizen Services
Records and State-26, Passport Records.
DISCLOSURE: Failure to provide the information requested on this form may result in the refusal or denial of a U.S. passport
application.

PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time required for
searching existing data sources, gathering the necessary data, providing the information and/or documentation required, and
reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control
number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to:
U.S. Department of State, Bureau of Consular Affairs, Passport Services, Office of Program Management and Operational Support,
2201 C Street NW, Washington, D.C. 20520.
DS-3053

02-2013

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U.S. Department of State
STATEMENT OF CONSENT:
ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16

OMB APPROVAL NO: 1405-0129
EXPIRATION DATE: XX-XX-XXXX
ESTIMATED BURDEN: 5 Minutes

Attention: Read WARNING and FORM INSTRUCTIONS on page 1

1. MINOR'S NAME
Last

First

Middle

2. MINOR'S DATE OF BIRTH (mm/dd/yyyy)

3. STATEMENT OF CONSENT To be completed by the non-applying parent or guardian using his/her information when not
present at the time the applying parent or guardian submits the minor's application. Statements expire after 90 days.

I,

, give my consent to the issuance of a United States passport to
my minor child named on this application.

Print Name (non-applying parent)

Apartment

Street Address (non-applying parent)
(

City

Zip Code

State

)
Area

E-mail Address

Telephone Number

STOP! YOU MUST SIGN THIS FORM IN FRONT OF A NOTARY.
OATH: I declare under penalty of perjury that all statements made in this supporting document are true and correct.

Signature of Non-Applying Parent or Guardian

Date (mm/dd/yyyy)

NOTE: A clear photocopy of the front and back of the identification you presented to the notary is required with this form.

4. STATEMENT OF CONSENT NOTARIZATION

Name of Notary
Print Name (Notary Public)

Location
City, State

NOTARY
SEAL

Commission Expires
Date (mm/dd/yyyy)

Identification Presented
by Non-Applying Parent or
Guardian:

Driver's License

ID Number:

Passport

Military ID

Other (specify)

Place of Issue:

Issue Date (mm/dd/yyyy):

Expiration Date (mm/dd/yyyy):

OATH: By signing this document, I certify that I am a licensed notary under laws and regulations of the state or country for which I am
performing my notarial duties, that I am not related to the above affiant, that I have personally witnessed him/her sign this document, and
that I have properly verified the identity of the affiant by personally viewing the above notated identification document and the matching
photocopy.

Signature of Notary

Date of
Notarization
Date (mm/dd/yyyy)

DS-3053 02-2013

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