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DS-5525 08-2013 Page 1 of 2 OMB CONTROL NO. 1405-0216 OMB EXPIRATION DATE 08-31-2016 1. Minor s Name Last First Middle 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 USE OF THIS FORM 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*...
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