DS 3053 Consent For Minors To Travel
DS 3053 Consent For Minors To Travel
DS 3053 Consent For Minors To Travel
Department of State
STATEMENT OF CONSENT:
ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16
FORM INSTRUCTIONS
1. Complete fields 1, 2, and 3. If field 3 is not completed, authorization will be valid for both products.
2. Complete field 4, 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 field 5.
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 presented to the notary 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.
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 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].
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.
1. MINOR'S NAME
Last First Middle
2. MINOR'S DATE OF BIRTH (mm/dd/yyyy) 3. THIS AUTHORIZATION IS VALID FOR:
Passport Book and Card Book Only Card Only
4. 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, authorize
Print Name (non-applying parent/guardian) Print Name (person applying for minor's passport)
to apply for a United States passport for my minor child named on this application. My consent is unconditional in regards to passport validity and travel.
( )
Area Code Telephone Number E-mail Address
NOTE: A clear photocopy of the front and back of the identification you presented to the notary is required with this form.
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 Driver's License Passport Military ID Other (specify)
Guardian:
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.
Date of
Signature of Notary Notarization
Date (mm/dd/yyyy)