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USE OF THIS FORM FORM INSTRUCTIONS SPECIAL …

The information collected on this form is used in conjunction with the DS-11, "Application for a Passport." When a minor under the ageof 16 applies for a passport and one of the minor's parents or legal guardians is unavailable at the time the passport is executed, a completedand notarized DS-3053 can be used as the statement of consent. If the required statement is not submitted, the minor may not be eligible toreceive a passport. The required statement may be submitted in other formats provided they meet statutory and OF THIS FORM DS-3053 08-2016 Page 1 of 2 For passport and travel information, please visit our website at 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 Customer Service Representatives are availableMonday-Friday, 8:00 - 10:00 Eastern Standard Time (excluding federal holidays).

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 Legal Affairs and Law Enforcement Liaison, Attn: Forms Officer 44132 Mercure Cir, P.O. Box 1227, Sterling, Virginia 20166-1227.

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