Response

Privacy Act Consent Form — U.S. Department of State (Passports)

In accordance with the provisions of The Privacy Act of 1974 (5 U.S.C. § 552a ), your written consent is required so that we may contact a federal agency on your behalf. Since e-mails do not contain a valid signature, they do not fulfill the requirements of the law.
-All information must be written in English (Toda la información debe estar en Inglés) (Tout enfòmasyon yo dwe ekri nan lang angle)
-One Consent Form per person requesting assistance is required

PRIMARY APPLICANT / PARENT OR GUARDIAN

Prefix

First Name

Last Name

Address

City

State

Zip

Daytime Phone

Cell Phone

Date of Birth

Social Security Number

Place of Birth:

MINOR APPLICANT (REQUIRED IF THE PASSPORT APPLICATION IS FOR A MINOR)

All information must be written in English (Toda la información debe estar en Inglés) (Tout enfòmasyon yo dwe ekri nan lang angle)

Minor's Name: (Please include the Minor's Full Name: First, Middle, Last and Suffix)

Minor's Date of Birth:

Minor's Place of Birth:

Minor's Social Security Number:

THIRD PARTY AUTHORIZATION (OPTIONAL)

If you want information regarding your case released to a third party (spouse, family, attorney, etc.) please provide the following information:

All information must be written in English (Toda la información debe estar en Inglés) (Tout enfòmasyon yo dwe ekri nan lang angle)

Name(s) and relationship:

E-mail:

Third Party Contact Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Daytime Phone

Cell Phone

ADDITIONAL INFORMATION

All information must be written in English (Toda la información debe estar en Inglés) (Tout enfòmasyon yo dwe ekri nan lang angle)

Proof of Travel must be submitted with this form-i.e. official itinerary showing your name and date of travel.

Travel Date:

Have you filed your passport application with the Department of State? Yes
No

If Yes, please provide your Locator Number(s) (if any):

Are you requesting an in-person appointment at a passport office? Yes
No

If you have contacted another congressional office to assist you, please list the office:

All information must be written in English (Toda la información debe estar en Inglés) (Tout enfòmasyon yo dwe ekri nan lang angle)

Briefly state your problem and the outcome you are seeking below. (Space is limited to 1,500 characters)

Please attached the supporting documents, up to three files and no larger than 15MB a piece.

Proof of Travel must be submitted with this form-i.e. official itinerary showing your name and date of travel.

Upload FileNo file chosen

2nd Attachment

Upload FileNo file chosen

3rd Attachment

Upload FileNo file chosen

DATE AND SIGNATURE

I hereby authorize the U.S. Consular Office of the United States of America and the U.S. Department of State to release information regarding me to the Office of U.S. Senator Marco Rubio. Further, I authorize the Office of Senator Marco Rubio to make appropriate inquiries on my behalf pertaining to my request for assistance, including any relevant information associated with my request.

Today's Date:

This signature must be from an individual who is 18 years of age or older. Third party signatures, including those of immediate family members, are not acceptable.

Signature must be in your handwriting.

Sign using your mouse or finger...