Form DS-3053 Statement of Consent: Issuance of a US Passport to a Min

U.S. Department of State

STATEMENT OF CONSENT:
U.S. PASSPORT ISSUANCE TO A CHILD

OMB Control No.: 1405-0129
Expiration: 12-31-2023
Estimated Burden: 20 Minutes

Print legibly or type using black ink only. If you make an error, complete a new form. Do not correct.
USE OF THIS FORM
This form is used with a U.S. passport application (Form DS-11) when one or both legal parents and/or legal guardians cannot appear in person with their minor
child to apply for their child’s U.S. passport. Both legal parents/legal guardians may also use this form to authorize a third party to apply for a child's passport on
the parents/guardians’ behalf. A separate notarized written statement with all details in this form may be submitted in lieu of this form.
• Children Under Age 16: Both legal parents/legal guardians must appear in person with their minor child to apply for a U.S. passport. If one or both
parent/guardian(s) cannot appear in person with their child, they must submit this form or a separate statement consenting to passport issuance which must be
signed and sworn under oath before a notary.
Children Ages 16 and 17: Parental awareness is required by one legal parent/legal guardian to issue the child a U.S. passport. In many cases, the
passport authorizing officer may be able to ascertain parental awareness of the passport application. However, the passport authorizing officer retains
discretion to request the legal parent/legal guardian’s written consent to passport issuance. Visit travel.state.gov for more details.
• Institutions or Entities Granted Guardianship to Child: Submit the documents below with this form or a separate statement and ensure the documents have
no conditions placed on the passport’s validity period and where the child may travel. If there are conditions in the consent, new consent is required.
1. A certified court order granting guardianship to the institution/entity. Photocopies are not acceptable.
2. A signed statement on the institution's/entity's letterhead authorizing a specific person to apply for the child’s passport on the child's behalf. The statement
must include the child's name and the name of the individual(s) authorized to apply for the passport.
3. The authorized individual’s photocopied employee photo identification verifying employment with the institution/entity.
NOTE: Consent may not be required if the legal parent/legal guardian submits evidence of sole authority to apply for the child’s passport such as the other parent’s
death certificate (if said parent is deceased), court order granting sole legal custody, or birth certificate listing only one parent. The parent may also submit for
consideration Form DS-5525 or written statement (made under penalty of perjury) explaining, in detail, why the second parent cannot be reached. Visit
www.travel.state.gov for more details.
HOW TO COMPLETE THIS FORM
 Sections 1, 2, and 3 are completed by the child’s non-applying legal parent(s)/legal guardian(s) also known as the “affiant(s)”. Consent is valid for both
passport book and card unless specified by writing “issue passport book only” or “issue passport card only” in Section 3.
 Stop at Section 4. The affiant(s) must wait to sign in front of a notary. The signed date of the affiant(s) and notary must match. The notary must not be related
to the affiant(s).
 The affiant(s) must attach with this form a photocopy of the front and back of the valid government-issued photo identification presented and notated on this
form or statement by the notary.
 Consent is valid for 90 days from the notary’s signed date. If this consent expires before submitting the U.S. passport application for the said-named child, new
consent is required.
 Notaries Outside the United States: In certain countries, this form or statement must be notarized at a U.S. embassy or consulate and cannot be notarized
by a local notary public. Go to the U.S. embassy or consulate webpage for more information.
CONTACT INFORMATION FOR PASSPORT SERVICES AND INTERNATIONAL PARENTAL CHILD ABDUCTION
Website
Email
Phone
•

Passport Services
National Passport Information Center (NPIC)
International Parental Child Abduction
Office of Children's Issues

travel.state.gov

NPIC@state.gov

1-877-487-2778
(TDD/TTY 1-888-874-7793)

travel.state.gov/childabduction

PreventAbduction1@state.gov

1-888-407-4747

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.
PRIVACY ACT STATEMENT
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 applicants under the age of 16, or one-parent consent when
requested by the Department for applicants ages 16 or 17, consistent with 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-26,
Passport Records, and State-05, Overseas Citizen Services Records and Other Overseas Records.
DISCLOSURE: Providing information on this form is voluntary. Failure to provide the information requested on this form may cause delays in processing.
PAPERWORK REDUCTION ACT
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 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, Bureau of Consular Affairs, Passport Services, Office of Program Management
and Operational Support, Attn: Passport Forms Officer, 44132 Mercure Cir, PO Box 1199, Sterling, Virginia 20166-1199.
DS-3053 12-2020

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U.S. Department of State

OMB Control No.: 1405-0129
Expiration: 12-31-2023
Estimated Burden: 20 Minutes

STATEMENT OF CONSENT:
U.S. PASSPORT ISSUANCE TO A CHILD

Print legibly or type using black ink only. If you make an error, complete a new form. Do not correct.

Reset Form

SECTION 1. CHILD APPLYING FOR A U.S. PASSPORT
Print your child’s name as it appears on the passport application (Form DS-11) and child’s birthdate.
b. Child’s Birthdate (MM-DD-YYYY)
a.Child’s Name (LAST, FIRST MIDDLE)
Example: SMITH, JOHN ROBERT
Check box if age 16 or 17
SECTION 2. ADULT APPLYING IN PERSON WITH CHILD UNDER AGE 16
Print name of adult appearing in person to apply for a U.S. passport and relationship to the above-named child.
a. Applying Adult’s Name (LAST, FIRST MIDDLE)
b. Applying Adult’s Relationship to Child (Check one)
Legal Parent

Legal Guardian

Third Party

SECTION 3. STATEMENT OF CONSENT FOR PASSPORT ISSUANCE TO THE CHILD
In blank space 1 (and blank space 2, if applicable) below, print the full name(s) of the legal parent/legal guardian(s) who cannot
appear in-person with the minor child to apply for the passport. Then complete the address and contact details in the boxes below.
I/We, 1)___________________________________________ and 2)______________________________________________,
consent to the issuance of a United States passport to the minor child. I/We consent for the adult named in Section 2 to
accompany the minor child and to execute the passport application if the minor child is under age 16. This consent is
unconditional regarding passport validity and travel. This consent is valid for the issuance of a U.S. passport book and card
unless otherwise stated in writing here
_____________________________________________________________
Example: “Issue passport book only” or “Issue passport card only”
1) Non-Applying Legal Parent/Guardian Address and Contact Details

2) Non-Applying Legal Parent/Guardian Address and Contact Details
Check box if same as 1

Street Address: _____________________________________ Street Address: _____________________________________
City, State/Country, Zip Code: __________________________ City, State/Country, ZipCode: __________________________
Phone: ____________________________________________ Phone: ____________________________________________
Email: ____________________________________________
Email:_____________________________________________
SECTION 4. OATH/AFFIRMATION. STOP HERE! Do not sign this form until requested to do so by a notary.
This section must be signed by the affiant(s) named in Section 3 of this form.
OATH: I solemnly swear (or affirm) that the above information given by me is true and correct to the best of my knowledge and
belief.
______________________________________________
______________________________________________
1) Non-Applying Legal Parent/Legal Guardian Signature
2) Non-Applying Legal Parent/Legal Guardian Signature
_______________________________
Date

_______________________________
Date

1) Non-Applying Legal Parent/Guardian Identifying Documents:
Driver’s License
Passport
Military
Other______

2) Non-Applying Legal Parent/Guardian Identifying Documents:
Driver’s License
Passport
Military
Other________

Name: ___________________________________________

Name: ____________________________________________

ID Number: ______________________________________

ID Number: ________________________________________

Place of Issue: ____________________________________

Place of Issue: ______________________________________

Issue Date: ______________

Issue Date: ______________

Expire Date: _____________

Expire Date: _____________

On the date specified above and below, the affiant(s) listed above who is/are not related to me, personally appeared before
me and executed this consent for the uses and purposes therein contained. I have properly verified the identity of the affiant(s)
by personally viewing the above-notated identification document(s) and matching photocopy(ies).
Notary Signature

Date

Location
(Agency or City, State)

SEAL

Attach a clear photocopy of the front and back of the valid government-issued photo identification presented
to the notary. This consent is valid for 90 days from the notary’s signed date. If this consent expires before
submitting the U.S. passport application for the above-named child, new consent is required.
DS-3053 12-2020

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