Form DS-5525: Statement of Exigent/Special Family Circumstances

Form DS-5525: Statement of Exigent/Special Family Circumstances

Applying for a child passport (minor passport) can be overwhelming and complicated. The child passport process has a few extra required forms, so please take your time and proceed carefully. If you need a passport in two weeks or less, we can help. Routine processing for a child passport is 4-6 weeks. If you need a minor passport faster (expedited), then we can make it happen. Please refer to our Child (Minor) Passport checklist for passports made in 2 weeks or less, even as fast as 24 hours.

 

The Form DS-5525: Statement of Exigent/Special Family Circumstances is a form that is used if one of the parents or guardians is not available to give consent. You can submit Form DS-5525: Statement of Exigent/Special Family Circumstances if you are the applying parent and you want to explain why the non-applying parent/guardian’s consent could not be obtained. The statement will explain in detail the circumstances as to why the non-applying parent or guardian is unavailable. The Form DS-5525: Statement of Exigent/Special Family Circumstances will also need to state the efforts made to contact the non-applying parent or guardian. Evidence should be given, which may include custody orders, incarceration orders, or a restraining order. These documents will help for the Form DS-5525: Statement of Exigent/Special Family Circumstances to be approved. For additional assistance on how to complete the DS-5525, please visit our helpful blog post How to Complete the DS-5525 Passport Form.

 

Applying for a Child Passport without the Parents or Guardians

If you are applying for a child passport without the parents or guardians present, you must have a notarized written statement or an affidavit from both parents or guardians. This statement must authorize the third party to apply for a minor’s passport.

Don’t let the complex child passport (minor passport) application process cause any delays to your trip. If you need a passport fast, we will work on your behalf to get the child passport in two weeks or less, even as fast as 24 hours. If you have any questions about the Form DS-5525: Statement of Exigent/Special Family Circumstances, please call or email us.

 

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USE OF THIS Form DS-5525: Statement of Exigent/Special Family Circumstances
FORM INSTRUCTIONS
1. Please complete the questions on this form to the best of your knowledge. Generally, the more information you are able to provide, the faster we may be able to process your U.S. passport application.
2. If you are unsure of the answer to a question, please provide a response to the best of your knowledge.
For example, if you are unsure of an exact address, please provide the city, state, or street name if you can recall them. Passport Services will consider all the information derived from the form in its entirety.
3. If you have no knowledge of the answer to a question, please write “I don’t know.”
4. If you need more space to respond to a question, please write the rest of your response on a separate sheet of paper. 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. Passport applications for minors under the age of 16 require both custodial parents/legal guardians’ signatures unless a notarized, written statement of consent from the non-applying custodial parent/legal guardian is provided. Use this form only if the notarized, written consent of a parent or legal guardian with custody of the minor applicant under 16 cannot be obtained. Your statement in the form must explain the reason why you cannot obtain the notarized statement of consent. You must show that there
are exigent or special family circumstances that make two parent/guardian consent unobtainable. Your request may qualify as an exigent circumstance if there is a time-sensitive emergency and the inability of the minor to obtain a passport would jeopardize the minor’s health or welfare. Your request may qualify as a special family circumstance
if the minor’s family situation makes it exceptionally difficult or impossible for one or both of the minor’s custodial parents/legal guardians to provide the notarized, written consent.
FOR MORE INFORMATION AND/OR QUESTIONS
For passport and travel information, please visit our website at travel.state.gov
In addition, contact the NationalPassport 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 Monday-Friday, 8:00a.m.-10:00p.m. Eastern Standard Time (excluding federal holidays). Automated information is available 24/7. For information on International Parental Child Abduction, please visit www.travel.state.gov/childabduction or contact the Office of Children’s Issues by telephone at 1-888-407-4747 or by e-mail at PreventAbduction@state.gov
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 this information is to establish a possible exigent
/special family circumstance exception to Public Law
106-113, Section 236, requiring two parent consent for a minor’s passport application.
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-05, Overseas Citizen Services Records and State-26, Passport Records.
DISCLOSURE:
Failure to provide the information requested on this form may result in the refusal or denial of a U.S. passport application.
PRIVACY ACT STATEMENT
WARNING
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 30 minutes per
response, including the timerequired for searchingexisting data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection.
Responding to this collection of information is required to obtain a benefit. 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,
2201 C Street NW, Washington, D.C. 20520.
DS-5525 08-2013
Page 1 of 2
U.S. Department of State
STATEMENT OF EXIGENT/SPECIAL FAMILY CIRCUMSTANCES
FOR ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16
3. Non-Applying Parent/Guardian’s Name
(Last, First, Middle)
9. Please explain in detail the reason for your request to issue a U.S. passport book and/or card without the
non-applying parent/guardian’s consent. If you cannot locate the non-applying parent/guardian, please
describe the number of attempts made to contact him or her, exact or approximate dates, the types of attempts
(i.e., by letter, phone, e-mail, or in-person), and the outcome of each attempt. Please include the non-applying
parent/guardian’s last known address, telephone number(s), and place of employment.
6. Non-Applying Parent/Guardian’s Last Known Contact Information
City
ZIP Code
State
Apartment
Street
7. Has any court either in the United States or abroad ever issued an order/decree that references the custody
or travel of the minor child in question? (Examples include a divorce decree, custody order, protection order,
stay away order, restraining order, etc.)
No
Yes
If yes, you must provide a complete, signed, and dated copy of the order(s)/decree(s) with this form.
Telephone Number: ( )
E-mail Address:
STATEMENT OF EXIGENT/SPECIAL FAMILY CIRCUMSTANCES
FOR ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16
10. Have you attempted to contact the non-applying parent/guardian through any third party? If yes, please list
the name of the person contacted, the relationship of the person contacted to the non-applying parent/guardian,
the dates of the attempts to contact, and the
address and/or telephone number of the contact.
DS-5525 08-2013
8. Is the non-applying parent/guardian currently incarcerated?
(consent from the incarcerated parent/guardian may be required)
Yes No
Page 2 of 2
2. Minor’s Date of Birth
(mm/dd/yyyy)
5. Non-Applying Parent/Guardian’s Date of Birth
(mm/dd/yyyy)
First
Middle
Last
If yes, please provide any documentation with this form, such as
a letter from the convicting criminal court, a copy of the incarceration
court order, or a copy of the on-line inmate locator page.
1. Minor’s Name
(Last, First, Middle)
4. Other Names of Non-Applying Parent/Guardian
OMB CONTROL NO. 1405-0216
OMB EXPIRATION DATE: 08-31-2016
ESTIMATED BURDEN: 30 Minutes
Signature of Parent
or Legal Guardian: Date
(mm/dd/yyyy)
:
U.S. Department of State
Country
OATH: I declare under penalty of perjury that all statements made in this supporting document are true and correct.