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ARNING and FORM INSTRUCTIONS on page 1 1. MINOR'S NAME Last First 2. MINOR'S DATE OF BIRTH Middle 3. YOUR RELATIONSHIP TO MINOR (mm/dd/yyyy) 4a. STATEMENT OF CONSENT To be completed by the non-applying parent or guardian when he or she will not be present at the time the applying parent or guardian submits the minor's application. Statement must not be more than 3 months old. I, , give my consent to the issuance of a United States passport to Print Your Name my minor child named on this.

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