Statement of Consent

PAPERWORK REDUCTION ACT STATEMENT
DS-3053 08-2013 Page 1 of 2
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 (T DD 1 -888-8 74-779 3) or by e-mail at N [email protected] C ustomer Service R epre sentatives are availa bl e Mond ay- Frid ay,
8:00 a.m. - 10:00 p.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 Prev[email protected]
PRIVACY ACT STATEMENT
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 pa ssport 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.
4. Please submit this form with your minor child's new DS-11 passport application to any designated acceptance facility, U.S. Passport Agency, U.S.
Embassy, or U.S. Consulate abroad.
STATEMENT OF CONSENT:
ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16
FORM INSTRUCTIONS
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
U.S. Department of State
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.
Public reporting burden for this collection of information is estimated to average 20 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 co ntrol number. If you have comments on the accu racy 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.
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 prot ect 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.
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