STATEMENT OF EXIGENT/SPECIAL FAMILY CIRCUMSTANCES FOR ISSUANCE OF A U.S. PASSPORT TO A CHILD UNDER AGE 16 - Form

Sep 16, 2026

Uploaded by Bulrr

U.S. Department of State form used for passport applications for children under 16 when notarized written consent from the non-applying parent or legal guardian cannot be obtained. The request must explain why consent is unobtainable and demonstrate qualifying exigent or special family circumstances, including time-sensitive emergencies or exceptionally difficult family situations. Completing the form does not guarantee issuance, and applicants are required to answer questions fully and truthfully.

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U.S. Department ofState STATEMENT OF EXIGENT/SPECIAL FAMILY CIRCUMSTANCES FOR ISSUANCE OF A U.S. PASSPORT TO A CHILD UNDER AGE 16 Please print legibly using black ink only. If you make an error, complete a new form. Do not correct. OMB Control No. 1405-0216 Expiration Date: 12/31/2028 Estimated Burden: 30 Minutes | WHEN TO USE THIS FORM | | --- | | Passport applications forchildren under the age of 16 require both parents/legal guardians' signatures unless a notarized, written statement of consent from the non-applying parent/legal guardian is provided. Use this form only if you cannot obtain the notarized, written consent of a parent or legal guardian with legal custody of the child applicant under 16.
Your statement in this form must explain the reason why you cannot obtain the notarized statement ofconsent. You must demonstrate that there are exigent or special family circumstances that make two parent/guardian consent unobtainable.
􀂃 Exigent Circumstance: Your request may qualify as an exigentcircumstance if there is a time-sensitive emergency, and the inability ofthe child to obtain a passport would jeopardize the child's health or welfare and safety or would result in the child being separated from the restofthe child's traveling party.
􀂃 Special Family Circumstance: Your request may qualify as a special family circumstance if the child's family situation makes it exceptionally difficult or impossible for one or both of the child’s parents/legal guardians to provide the notarized, written statement ofconsent. | | IMPORTANT | | 1. Completing this form does not guarantee the child applicant will be issued a U.S. passport.
2. Please answer all questions on this form to the best of your knowledge. The more information you provide, the faster we may be able to process your child's U.S. passport application. For example, if you are unsure ofan exact address, please provide the street name, city, or state if you can. We will consider all the information on the form in its entirety.
3. If you need more space to respond toa question, please use a separate sheet of paper.
4. If you have a current court order showing full/sole legal custody or granting permission to obtain a passport, you may not need to fill out this form. Submit court orders with the child's passport application.
5. If you are unable togetin contact with an incarcerated non-applying parent (e.g., non-applying parent is confined to solitary and not permitted to receive or send mail or have contact with a notary; or non-applying parent is incarcerated overseas where the prison does not have a notary or other amenities), use this form. Otherwise, consent (see Form DS-3053) ora court order is still required. | | INFORMATION AND/OR QUESTIONS | | For passport and travel information, please visit[travel.state.gov. In addition](travel.state.gov. In addition), contact the National Passport Information Center (NPIC) toll-free at 1-877-487-2778 (TDD/TTY 1-888-874-7793) or by email (general information only) [at NPIC@state.gov. For](at NPIC@state.gov. For) information on International Parental Child Abduction, please visit childabduction.state.gov or contact the Office of Children's Issues by telephone at 1-888-407-4747 or by email at [PreventAbduction1@state.gov](PreventAbduction1@state.gov). | | 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.](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 etseq.; 8 U.S.C. 1104; 26 U.S.C. 6039E; Executive Order 11295 (August 5, 1966); [and 22 C.F.R. parts](and

FAQs

When should this statement form be used for a child under 16?

Use it when you cannot obtain a notarized, written consent statement from the non-applying parent or legal guardian with legal custody of the child under 16.

What must the statement explain and demonstrate?

The statement must explain why the notarized consent cannot be obtained and demonstrate exigent or special family circumstances that make two-parent/guardian consent unobtainable.

Does completing the form guarantee a U.S. passport will be issued?

No. Completing the form does not guarantee that the child applicant will be issued a U.S. passport.

Sep 16, 2026

Uploaded by Bulrr