Form DS-3077 Request for Entry into Children's Pasport Issuance Alert

U.S. Department of State

REQUEST FOR ENTRY INTO
CHILDREN'S PASSPORT ISSUANCE ALERT PROGRAM

*OMB CONTROL NO. 1405-0169
EXPIRATION DATE: XX-XX-20XX
ESTIMATED BURDEN: 30 Minutes*

REQUEST FORM An alert request may be filed with respect to a minor under the age of 18. This request can be filed
by concerned parents of U.S. citizen children, their appointed agents, or other persons having legal custody of the child.
Complete one form for each child, and submit the completed request along with proper documents to the Office of
Children's Issues by e-mail, fax, or mail. By signing this form you are affirming that you have parental rights to this child.
1. Please provide information about the child in order to make the alert system effective. Please print clearly or type
the information.
Date of Birth
(mm-dd-yyyy)

Child's Full Name (Last, First, Middle)

Child's Sex

Social Security Number

Female

2.

Place of Birth

U.S. Passport Number(s), if any

Male

Please provide the following information about yourself so that we can acknowledge your request, and alert
you in the future.
Date of Birth (mm-dd-yyyy)

Your Full Name (Last, First, Middle)

Place of Birth

Your Relationship to Documentation of Parentage, Guardianship, Legal Custody OR Authority to Act on Behalf of Parent or Legal Guardian, as
Child Shown Above applicable. Without this documentation, a child may not be enrolled in the Children's Passport Issuance Alert Program.
Birth Certificate

Consular Report of Birth Abroad (CRBA)

Adoption Decree

Current Custody/
Guardianship Court
Order(s)

Evidence of Authority to Act on
Behalf of Parent or Legal Custodian

Other

Documentation of Identity Provided
Driver's License

Passport

Mailing Address

Other Form of Photo Identification with Signature
City

State or Country

Postal Code

NOTE: Since the Department may need to contact you, it is very important that you keep us informed in writing or by
telephone of any changes to your contact information. Failure to notify this office of your correct address,
e-mail, and phone number may result in passport issuance for your child without your knowledge.
Home Phone

3.

Work Phone

Cell Phone

Email Address(es)

I request that the U.S. Department of State notify me if it receives a U.S. passport application for the
above-mentioned child, or if an application is currently pending, or if there is any U.S. passport still valid for
the child's travel.
I object to the Issuance of a U.S. Passport to the Aforementioned Child, but I understand that under
prescribed circumstances (see 22 CFR 51.28) the Department is authorized to issue the passport
nonetheless.

Signature

Date (mm-dd-yyyy)

Please read the dual nationality for children information accompanying this form. It relates to a child who may have a foreign nationality in addition
to U.S. nationality. Please see additional information on preventing abductions at our website, childabduction.state.gov.
Please submit via e-mail, fax, or mail the completed form along with copies of the original documents to the U.S. Department of State, Overseas
Citizen Services, Office of Children's Issues; Attention: Children's Passport Issuance Alert Program; SA-17, 9th Floor, Washington, DC 20522-1707;
Email: [email protected]; Telephone Number 1-888-407-4747, Fax Number 202-485-6222.
DS-3077
11-2018

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DUAL NATIONALITY FOR CHILDREN
Many children, born in the United States or born abroad to a U.S. citizen parent, are citizens of both the United States and another country. A
child may acquire the citizenship of a foreign country, for example, through the child's birth abroad, or through a parent. Many countries do not
require the consent of all parents in order to acquire nationality and/or a passport. Therefore, even though U.S. law may prevent one parent from
obtaining a U.S. passport for a child in the absence of two-parent consent, a parent may still be able to obtain a foreign passport for a dual national
child from the embassy or government of the other country. Under U.S. law, a U.S. citizen child is required to enter and depart the United States
on his or her U.S. passport. However, please be advised that U.S. citizen children may still be able to depart the United States undetected on
foreign passports.
U.S. laws and regulations concerning the issuance of U.S. passports do not apply to foreign governments issuing passports to people (including
children) considered citizens of that country, whether or not the foreign passport is issued in the United States and/or to a person the United States
considers to be a U.S. citizen. If you think there is a possibility that your child may have another nationality, you are encouraged to contact the
relevant country's embassy or consulate directly to inquire about the rules governing the issuance of that country's passport to your child, including
the possible availability of mechanisms to prevent the issuance to your child of that country's passport without your consent. The address and
telephone numbers for the embassies and consulates of foreign countries within the United States can be found on the Bureau of Consular Affairs
web page at travel.state.gov.

PRIVACY ACT STATEMENT
AUTHORITY: The information solicited on this form is requested pursuant to provisions in Titles 8 and 22 of the
U.S. Code, as well as the corresponding federal regulations, including specifically 22 U.S.C. § 211a and Public Law
106-113, Div. B, §1000(a)(7) [Div. A., Title II, §236] of the Admiral James W. Nance and Meg Donovan Foreign
Relations Authorization Act, Fiscal Years 2000 and 2001 and Executive Order 11295 (Aug. 5, 1966), and the
regulations contained in 22 C.F.R. § 51.28.
PURPOSE: The primary purpose for soliciting the information is to enable the U.S. Department of State to notify
you of any pending U.S. passport applications for the child identified on the form and of any U.S. passport held by
the child that is still valid for travel. The child's social security number is requested because that number is a
unique identifier used to establish the identity of the passport holder.
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. It may also be disclosed pursuant to court
order. 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. nationals
abroad. This would include, among other entities and agencies, disclosure to The National Center for Missing and
Exploited Children, Central Authorities of countries party to the Hague Convention on the Civil Aspects of
International Child Abduction ("the Convention"), attorneys of record and legal aid services to assist in facilitating
operations under the Convention; local police in connection with notification of next-of-kin and child custody
disputes; social services agencies; and parents involved in cases brought under the Convention. The information
may also be made available to private U.S. citizen 'wardens' designated by 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 user set forth in the System of Records Notice (SORN) for Overseas
Citizens Services Records (State-05)., found at: http://www.state.gov/m/a/ips/c25533.htm
DISCLOSURE: Filing a request through the Children's Passport Issuance Alert Program and providing the
information requested on this form, including the child's social security number, is voluntary. Failure to complete
the form may result in a passport being issued to your child without your knowledge.

PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including
time required for searching existing data sources, gathering the necessary documentation, providing the information
and/or documents 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,
CA/OCS/L, 10th Floor, WASHINGTON, DC 20522-1707.

DS-3077

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