Form DS-3013 APPLICATION UNDER THE HAGUE CONVENTION ON THE CIVIL ASPE

OMB NO. 1405-0076
EXPIRES: 02/29/2016
Estimated Burden - 1 Hour*

U. S. Department of State

APPLICATION UNDER THE HAGUE CONVENTION ON THE CIVIL
ASPECTS OF INTERNATIONAL CHILD ABDUCTION
FILL OUT ALL SECTIONS ON BOTH SIDES
*Provide information below to the extent that it is available.

This is an application for the

Return of

Access to the child/children listed below.

I. FIRST CHILD SUBJECT OF APPLICATION
Child's Name (Last, First, MI.)

Date of Birth (mm-dd-yyyy)

Address (At Time of Removal)

U.S. SSN*

Place of Birth

Passport/Identity Card*
Country
Number

Address and Telephone Number of Child's Current Location (If Known)

Weight

Height

Name of Child's Father if not Listed in Section II or III

Citizenship(s)

Color of Hair

Color of Eyes

Name of Child's Mother if not Listed in Section II or III3

II. APPLICANT (PERSON SEEKING RETURN OF/ACCESS TO CHILD/CHILDREN)
Name (Last, First, MI)

Relationship to Child/ren

Date of Birth (mm-dd-yyyy)

Citizenship(s)

U.S. SSN*

Place of Birth

Passport/Identity Card*
Country
Number
Occupation

Current Address, Telephone Number, and Email Address

Name, Address, and Telephone Number of Legal Advisor*

III. PERSON ALLEGED TO HAVE WRONGFULLY REMOVED OR RETAINED THE CHILD/CHILDREN
Name (Last, First, MI)

Relationship to Child/ren

Citizenship(s)

Date of Birth (mm-dd-yyyy)

Place of Birth

U.S. SSN*

Passport/Identity Card*
Country
Number
Known Aliases

Occupation, Name, and Address of Employer (If Known)

Address and Telephone Number of Current Location

Height

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04-2015

Weight

Color of Hair

Color of Eyes

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IV. ADDITIONAL CHILD/CHILDREN Subject of Application
Child's Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Place of Birth

Address (At Time of Removal)

U.S. SSN*

Passport/Identity Card*
Country
Number
Citizenship(s)

Address and Telephone Number of Child's Current Location (If Known)

Height

Weight

Color of Eyes

Color of Hair

Name of Child's Father if not Listed in Section II or III

Name of Child's Mother if not Listed in Section II or III

Child's Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Address (At Time of Removal)

U.S. SSN*

Place of Birth

Passport/Identity Card*
Country
Number
Citizenship(s)

Address and Telephone Number of Child's Current Location (If Known)

Height

Weight

Color of Hair

Color of Eyes

Name of Child's Father if not Listed in Section II or III.

Name of Child's Mother if not Listed in Section II or III.

Child's Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Place of Birth

Address (At Time of Removal)

U.S. SSN*

Passport/Identity Card*
Country
Number
Citizenship(s)

Address and Telephone Number of Child's Current Location (If Known)

Height

Weight

Color of Eyes

Color of Hair

Name of Child's Father if not Listed in Section II or III.

Name of Child's Mother if not Listed in Section II or III.

Child's Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Address (At Time of Removal)

U.S. SSN*

Place of Birth

Passport/Identity Card*
Country
Number
Citizenship(s)

Address and Telephone Number of Child's Current Location (If Known)

Height

Weight

Name of Child's Father if not Listed in Section II or III.

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Color of Hair

Color of Eyes

Name of Child's Mother if not Listed in Section II or III.

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ADDITIONAL SHEETS MAY BE ATTACHED

V. TIME, PLACE, DATE AND CIRCUMSTANCES OF THE WRONGFUL REMOVAL OR RETENTION
Additional sheets may be attached.

VI. FACTUAL AND LEGAL JUSTIFICATION FOR THE REQUEST
Habitual Residence (Please provide details related to the child's place of habitual residence.)

Basis of Applicants' Custody Rights
Supporting Documentation (Please check applicable boxes and attach.)
Law/Statute of Child's Residence at Time of Alleged Removal or Retention
Court Order in Effect at Time of Alleged Removal or Retention
Legally Binding Agreement
Marriage Certificate, If Applicable
Child's Birth Certificate, Required
Other

Are civil proceedings currently in progress? (If yes, please provide details.)

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Signing Instructions

ADDITIONAL SHEETS MAY BE ATTACHED

VII. PROPOSED ARRANGEMENTS FOR RETURN TRAVEL OF CHILD/CHILDREN

VIII. OTHER PERSONS WITH ADDITIONAL INFORMATION RELATING
TO THE WHEREABOUTS OF THE CHILD/CHILDREN
Preferably, in country of child's current location. Please include, name, address, telephone number, and /or email address.

IX. OTHER RELEVANT INFORMATION

Applicant Signature (Sign in Blue Ink)

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Date (mm-dd-yyyy)

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PRIVACY ACT STATEMENT
AUTHORITY: The information solicited on this form is requested under the authority of the
International Child Abduction Remedies Act, Public Law 100-300, codified at 22 U.S.C. 9001
et. seq.
PURPOSE: The primary purpose for soliciting the information is to evaluate applicants' claims
under the Hague Convention on the Civil Aspects of International Child Abduction, advise
applicants about available legal remedies, and locate abducted children.
Furnishing your social security number, as well as the other information requested on this form,
is voluntary. The social security number may be used, if necessary, to authenticate the
identities of individuals that are listed in the applicant claim.
ROUTINE USES: The information will be used to assist in facilitating operations under the
Convention and may be provided to governments of member countries, bar associations and
legal aid services, local police, social service agencies, and parents. This information may also
be released on a need-to-know basis to other government agencies, including foreign agencies,
having statutory or other lawful authority to gain access to such information. More information
on the Routine Uses for the system can be found in the System of Records Notice State-05,
Overseas Citizens Services Records.
DISCLOSURE: Providing the information requested on this form, including the child's social
security number, is voluntary. Failure to submit this form or to provide all the requested
information may result in delay in the processing of your application.
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 this information requested if the OMB approval has expired. Send
comments on the accuracy of this estimate of the burden and recommendations for reducing it
to: CA/OCS/PMO, SA-17, 10th Floor, U.S. Department of State, Washington, DC 20036 .

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