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Fillable Form DS-3053

Statement of Consent or Special Circumstance for Minor Passport is when one parent is applying for a passport for a child without the other parent or has sole custody of the minor.

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What is Form DS-3053?

DS-3053 is also known as the Statement of Consent: Issuance of a US Passport to a Minor Under Age 16. This form, when completed and notarized, is used as a statement of consent when the minor’s parents or legal guardians are unavailable at the time the passport is executed.

If this statement is not submitted, the minor may not be able to receive a US passport.

How to Fill Out Form DS-3053?

Line 1: Minor’s Name
Provide the minor’s full name. Include their last name, first name, and middle name.

Line 2: Minor’s Date of Birth
Provide the minor’s date of birth. Use the following format: (MM/DD/YY).

Line 3: Validation
Check the appropriate box whether the authorization form is valid for a passport book and card, a passport book only, or a passport card only.

Line 4: Statement of Consent
This section will be completed by the non-applying parent or guardian using his/her information when not present at the time the applying parent or guardian submits the minor’s application.

This statement expires after 90 days.

Provide the following:

1. The printed name of the non-applying parent or guardian,
2. The printed name of the person applying for the minor’s passport,
3. The residential address of the non-applying parent or guardian which includes the street address, apartment number, city, state, and zip code,
4. The telephone number of the non-applying parent or guardian which also includes the area code, and
5. The email address of the non-applying parent or guardian.

After ensuring that you have accomplished this form completely and accurately, sign and date this form in front of a notary.

Line 5: Statement of Consent Notarization
The information in this section will be provided by the notary.


Submit Form DS-3053 with the minor’s new DS-11 passport application to any designated acceptance facility, US Passport Agency, US Embassy, or US Consulate abroad.


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