Issuance Of A Passport To A Minor (Under Age Of 16) Page 2
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1
2CONTINUATION OF STATEMENT OF SPECIAL CIRCUMSTANCES:
FOR INFORMATION, QUESTIONS, AND INQUIRIES:
Please visit our website at travel.state.gov. In addition, contact the National Passport Information Center
(NPIC) toll-free at 1-877-487-2778
(TDD: 1-888-874-7793) or by e-mail at NPIC@state.gov. Customer
Service Representatives are available M-F, 6AM-12AM ET (excluding federal holidays). Hours and days
may be extended in relation to call volume. Automated information is available 24/7.
PRIVACY ACT STATEMENT
AUTHORITIES: The information solicited on this form is requested pursuant to 22 U.S.C. 211a, 212, 213, and Section
236 of the Admiral James W. Nance and Meg Donovan Foreign Relations Authorization Act, Fiscal Years 2000 and
2001; Executive Order 11295 (August 5, 1966); and 22 CFR 51.28.
PURPOSE: The primary purpose is to document the notarized written consent of a parent or legal guardian to the
issuance of a U.S. passport to a child under sixteen years of age, or, alternatively, to document the existence of exigent
or special family circumstances, when the parent or legal guardian is not present when an application is made for
issuance of a U.S. passport for the child.
ROUTINE USES: The information solicited on this form may be made available as a routine use to other government
agencies to assist the U.S. Department of State in adjudicating passport applications and requests for related services,
and for law enforcement and administrative purposes. The information may be made available to foreign government
agencies to fulfill passport control and immigration duties. The information may also be provided to foreign government
agencies, international organizations and, in limited cases, private persons and organizations to investigate, prosecute, or
otherwise address potential violations of law or to further the Secretary’s responsibility for the protection of U.S.
citizens and non-citizen nationals abroad. The information may be made available to private U.S. citizen ‘wardens’
designated by the U.S. embassies and consulates.
For a more detailed listing of the routine uses to which this
information may be put, see the Prefatory Statement of Routine Uses and the listing of routine users set forth in the
system descriptions for Overseas Citizen Services Records (State-05) and Passport Records (State-26) published in the
Federal Register.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: You are not legally required to provide the information
requested on this form. However, failure to do so may result in Passport Services’ refusal to accept your application or
result in the denial of a U.S. passport.
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 the information unless this collection displays a currently valid
OMB number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to:
U.S. Department of State (A/ISS/DIR) Washington DC 20520.
DS-3053
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