Ds-3013 Application Under The Hague Convention On The Civil Aspe

U. S. Department of State

APPLICATION UNDER THE HAGUE CONVENTION ON THE
CIVIL ASPECTS OF INTERNATIONAL CHILD ABDUCTION

OMB CONTROL NO. 1405-0076
EXPIRES: XX-XX-20XX
Estimated Burden - 1 Hour*

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. (Select only one)

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

Date of Birth (mm-dd-yyyy)

Place of Birth

Address (Habitual Residence at Time of Removal or Retention)

U.S. SSN

Passport/Identity Card
Country
Number

Address of Child's Current Location (If Known)

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

Height

Color of Hair

Weight

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

Color of Eyes

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

II. APPLICANT (PERSON SEEKING RETURN OF/ACCESS TO 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

Current Address

Telephone Number

Preferred Language

Occupation

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

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

Known Aliases

Address and Telephone Number of Current Location

Height

DS-3013
11-2018

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 (Habitual Residence at Time of Removal or Retention)

U.S. SSN

Passport/Identity Card
Country
Number

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

Height

Weight

Citizenship(s)

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 (Habitual Residence at Time of Removal or Retention)

U.S. SSN

Place of Birth

Passport/Identity Card
Country
Number

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

Height

Weight

Citizenship(s)

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 (Habitual Residence at Time of Removal or Retention)

U.S. SSN

Passport/Identity Card
Country
Number

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

Height

Weight

Citizenship(s)

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 (Habitual Residence at Time of Removal or Retention)

U.S. SSN

Place of Birth

Passport/Identity Card
Country
Number

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)

DS-3013

Citizenship(s)

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. CIRCUMSTANCES OF THE WRONGFUL REMOVAL OR RETENTION
Date of Wrongful Removal or Retention (mm-dd-yyyy)
Use approximate date if exact date unknown

Place of Wrongful Removal or Retention

Circumstances of Abduction (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
Required documentation, please select at least one
Supporting Documentation (Please check applicable boxes and attach.)
Law/Statute Relating to Custody for Child's Residence at Time of Alleged Removal or Retention
Court Order in Effect at Time of Alleged Removal or Retention
Legally Binding Agreement
Other
Are civil proceedings currently in progress? (If yes, please provide details.)

DS-3013

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ADDITIONAL SHEETS MAY BE ATTACHED

VII. PROPOSED ARRANGEMENTS FOR RETURN TRAVEL OF CHILD/CHILDREN
How will child return (i.e. flight)? Will you or someone you designate as a power of attorney accompany the child? Please provide as many details as
possible.

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, relationship to child/parent, address, and contact information.

IX. SUPPORTING DOCUMENTATION AND OTHER RELEVANT INFORMATION
Parents married?

Yes

No

If so, date:________If yes, marriage certificate must be attached.

Parents divorced?

Yes

No

If so, date:________If yes, divorce decree must be attached.

Custody Order existing at time of removal or retention? If so, please provide a copy of the order.

Applicant Signature (Sign in Blue Ink)

DS-3013

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, inform 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, attorneys, 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
and the Department's Prefatory Statement of Routine Uses.
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/L, 2201 C St., NW, SA-17;
10th Floor, U.S. Department of State, Washington, DC 20522-1710.
DS-3013

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