Fill - Free fillable Vzgq0d BoQ0u Hj2yquOKQ New Jersey Real World Notary Training Docs (City of Oakland) PDF form

New Jersey Notary 101

Real World Training

Laura J Biewer

CoachmeLaura.com

Roadmap

• Being prepared for

first assignment

• Recognize when

document needs

notarization

• Recognize 3 most

common acts

• When to use

attachments

• Identification and

Name Variation

• Journaling -

Recommended

• When to say NO to

requests/prohibited

docs

Tools

• Notary Tools

– Journal

– Blank

certificates

– Seal (s)

– Receipt book

for public

notarizations

– Good pens

– ID document

checker

– NJ Notary

Public Manual

published by

State Treas.

Notary 101

• How to recognize a

document needs a

notarization:

• Look for Original

Signature

• Look for Notarial

wording

• When to say Yes

• Legal and

reasonable

3 most common

Acts

Acknowledgment,

Jurat,

Oath/Affirmations

• How to recognize Jurat from

Acknowledgment

– Acknowledged to me,

Subscribed and sworn

• ACK WORDING: Must have the

word Acknowledge

RULE: May use NJ wording or any

other state as long as complies

with required elements

May take acknowledgment in

capacity-no proof required

• JURAT: KEY Words Subscribed and

Sworn….Rule: same as

Acknowledgment

• Oaths: Oath of office, oath to

witnesses, testimony

• Correcting certificates: not

addressed in statute

• Recommendation:

– Check journal to verify

performance of act

– Have document to confirm

certificate attached

– Clerical errors only

New Acts

effective

Oct 20

2021

• Certification of Copy of

documents and

depositions.

• Certify tangible copy of

an electronic record is an

accurate copy of the

electronic record

• Witness or attest

signatures also known as

signature witnessing.

– determine, from

personal knowledge

or satisfactory

evidence, that the

individual appearing

before the officer

and signing the

record has the

identity claimed.

Attachments

• When to use an

attachment instead

of what is provided.

– Wording is not

NJ and doesn’t

comply

– No room for your

seal of office

– Made a mistake

on the document

wording

– Certifications or

claims a NJ

notary cannot

make

– NO wording,

signer chooses

Identification

3 methods:

Personal Knowledge: know personally

not of them

ID CARDS:

(a) a passport, driver's license,

or government-issued, non-

driver identification card,

which is current or expired

not more than three years

before the performance of

the notarial act; or

(b) another form of

government-issued

identification, which is

current or expired not more

than three years before the

performance of the notarial

act, and which contains the

individual's signature or a

photograph of the

individual's face; and is

satisfactory to the notarial

officer

affirmation of a credible

witness personally

appearing before the officer

and personally known to the

officer or whom the officer

can identify on the basis of

an ID mentioned in (a)

above.

Authorizes a notarial officer to require an

individual to provide additional information or

identification credentials necessary to assure

the officer of the identity of the individual.

Name

Variation

• How to deal with name

variation

– Satisfactory

Evidence

– Reasonable

reliance/Evidence

that satisfies

• Nick names

• Maiden names

• AKA, FKA, PKA,

• Misspelled

Names

• Middle name

for first name

• 2 last names

– Supplementary

Evidence

Disabled

Signers

• Provides that if an

individual is physically

unable to sign a record,

the individual may direct

an individual other than

the notarial officer to

sign the record with the

individual's name.

• notarizing a record for an

individual physically

unable to sign, the

notarial officer must

insert "Signature affixed

by (name of other

individual) at the

direction of (name of

individual)" or words of

similar import.

Journaling

• Required tangible or

Electronic

• If the journal is maintained

on a tangible medium, it

must be a permanent,

bound register with

consecutively numbered

lines and consecutively

numbered pages.

• if the journal is maintained

in an electronic format, it

must be in a permanent,

tamper-evident electronic

format complying with any

rules and regulations

promulgated by the State

Treasurer in the New

Jersey Notary Public

Manual.

Journaling

• Provides that the Notary must

either retain the journal for 10

years after the performance of

the last notarial act recorded

in the journal or transmit the

journal to the Department of

the Treasury,

• Authorizes that in lieu of

maintaining a journal, a

Notary who is an attorney-at-

law admitted to practice in

New Jersey, or who is

employed by an attorney-at-

law, or who is employed by or

acting as an agent for a title

insurance company licensed to

do business in New Jersey

pursuant NJSA 17:22A-26 et

seq., to maintain a record of

notarial acts in the form of

files regularly maintained for

the attorney's law practice or

the title insurance company's

business activities, as the case

may be

Journaling

• How to fill out the

Journal

– Date and Time of

Appearance

– Type of Notary

Act

– Name of

Document/date

signed

– Type of ID & date

of exp or issuance

– statement of

Satisfactory

evidence

– Name and

Address of

signer/witness

– Signer signature

Journaling

Optional

– Place of

notarization

– The Additional

info

• Notes

• Who is paying

• Document

witnesses

• Special

Circumstances

Certificates

• Requires a notarial

act to be evidenced

by a certificate of

notarial act

• Requires a certificate

of notarial act to (a)

be executed

contemporaneously

with the

performance of the

notarial act

• a certificate of

notarial act is

sufficient if it

conforms to the

general

requirements for a

notarial certificate

Seal of

office

• Requires a Notary to

use an official stamp

on a tangible and

electronic record.

• Requires the official

stamp to include the

name of the Notary,

the title "Notary

Public, State of New

Jersey," and the

Notary's commission

expiration date.

• Requires the official

stamp to be capable

of being copied

together with the

record to which it is

affixed

Fees

Repealed Statutory fees

Notaries may continue

charging

a fee per notarial

act

, the maximum amount

has been determined by

the State Treasurer.

$2.50/acknowledgement

$2.50/Jurat

$2.50/oath/affirmation

$2.50/ Proof

New acts not published

yet

Travel fees have not

changed.

Miscellaneous

• May be resident or have

place of employment or

practice law then dual

commission with other

state ok.

• a nonresident applicant

who is an employee of a

business with its domicile

or primary place of

business in New Jersey

and performs his

employment duties

remotely from a home

office or a co-working

space can apply to

receive a Notary

commission.

Micellaneous

• Prohibits a notarial

officer from

performing a

notarial act with

respect to a record

to which the

officer or the

officer's spouse or

civil union partner

is a party, or in

which either of

them has a direct

beneficial interest

Foreign

Language

Advertising

• The Notary must

provide the

following

statement or a

translation of the

statement if the

advertisement is

not in English: "I

am not an attorney

licensed to practice

law and may not

give legal advice

about immigration

or any other legal

matter or accept

fees for legal

advice."

Notarization

and

RON/RIN

• Both are allowed in NJ

must inform State

Treas office before

initial act using

technology

– Electronic the

signer is in front

of you

– RON the signer is

remotely located

anywhere in the

world while you

are in NJ

• Recommend you first

understand how to

notarize traditionally

before taking on the

technology part as

well as the customer

tech support

Just say No

• When to say no to a

notarization

– Document

disqualified

• Incomplete or

Blank

• No notarial act,

and signer

cannot choose

• No signature

required

• Not a qualified

notarial act ie:

Cert of Life,

Just say No

– Notary Disqualified

• Conflict of interest

– Self

notarization

spouse

– Singer Disqualified

• physical

appearance/sig

does not conform

to ID

• No qualified ID

from list

• No physical

appearance

• Not alert and

aware

– Other Disqualifications

• Suspect

fraud/illegal

• Outside of

business hours

Hands On

• Exercise 1

Recognition

– Does it need

notarization

– Can I use the

wording or

need a loose

certificate

• Exercise 2

Completion of Cert

– Fill out

certificate for

each document

General

Business

Tips

• Receipt book

– Separate notary

fee from all

other fees

• Travel Fees

– Not regulated,

agree with signer

ahead

• Other fees

– Printing/scannin

g/faxing/courrier

– After business

hours/holidays

Assistance

• TNT Calls: Tuesdays noon PST www.notarycoach.com/TNT

• E Meet ups:https://www.notarycoach.com/litereplay

• NNA Articles: www.nationalnotary.org/knowledgecenter

• NNA Hotline 888-876-0827 (membership/kit of supplies) free shipping code

50321 for internet orders

• LBP Replay Library www.coachmeLaura.com

• Notary Symposium: Virtual-Live Nov 6, 2021 www.notarysymposium.com

• Quick Calls www.coachmelaura.com

• Legal Services: www.Lbiewer.wearelegalshield.com

Page 1 of 2

Prepared By

Name: _____________________________

Address: ___________________________

___________________________________

State: _____________ Zip Code: ________

After Recording Return To

Name: _____________________________

Address: ___________________________

___________________________________

State: _____________ Zip Code: ________

Space Above This Line for Recorder’s Use

NEW JERSEY GENERAL WARRANTY DEED

STATE OF NEW JERSEY

____________________ COUNTY

KNOW ALL MEN BY THESE PRESENTS, That for and in consideration of the sum of

___________________________ ($__________________) in hand paid to

_____________________, a _________________, residing at ___________________,

County of ___________, City of _______________, State of _______________

(hereinafter known as the “Grantor(s)”) warrants generally the property hereby

conveyed against all persons whomsoever to _____________________, a

_________________, residing at ___________________, County of ___________, City

of _______________, State of _______________ (hereinafter known as the

“Grantee(s)”) all the rights, title, interest, and claim the property hereby granted in or to

the following *described real estate (*and in Exhibit A if attached), situated in

___________________ County, New Jersey to-wit:

______________________________________________________________________

[INSERT LEGAL DESCRIPTION HERE AND/OR ATTACH EXHIBIT A]

TOGETHER WITH all the rights, members and appurtenances to the Real Estate in

anywise appertaining or belonging thereto.

Page 2 of 2

TO HAVE AND TO HOLD, the tract or parcel of land above described together with all

and singular the rights, privileges, tenements, appurtenances, and improvements unto

the said Grantees, their heirs and assigns forever.

And said Grantors, for said Grantors, their heirs, successors, executors and

administrators, covenants with Grantees, and with their heirs and assigns, that Grantors

are lawfully seized in fee simple of the said Real Estate; that said Real Estate is free

and clear from all Liens and Encumbrances, except as hereinabove set forth, and

except for taxes due for the current and subsequent years, and except for any

Restrictions pertaining to the Real Estate of record in the Probate Office of said County;

and that Grantors will, and their heirs, executors and administrators shall, warrant and

defend the same to said Grantees, and their heirs and assigns, forever against the

lawful claims of all persons.

IN WITNESS WHEREOF, Grantor has executed and delivered this General Warranty

Deed under seal as of the day and year first above written.

________________________________ ________________________________

Grantor’s Signature Grantor’s Signature

________________________________ ________________________________

Grantor’s Name Grantor’s Name

________________________________ ________________________________

Address Address

________________________________ ________________________________

City, State & Zip City, State & Zip

STATE OF NEW JERSEY)

COUNTY OF ___________________)

I, the undersigned, a Notary Public in and for said County, in said State, hereby certify

that ______________________________ whose names are signed to the foregoing

instrument, and who is known to me, acknowledged before me on this day that, being

informed of the contents of the instrument, they, executed the same voluntarily on the

day the same bears date.

Given under my hand this ____ day of ____________________, 20___.

____________________________________

Notary Public

My Commission Expires: ______________

New Jersey Last Will and Testament

___________________________________

Pursuant to Title 3B (Administration of Estates - Decedents and Others)

I, ________________________, resident in the City of ____________________,

County of ____________________, State of New Jersey being of sound mind, not

acting under duress or undue influence, and fully understanding the nature and extent

of all my property and of this disposition thereof, do hereby make, publish, and declare

this document to be my Last Will and Testament, and hereby revoke any and all other

wills and codicils heretofore made by me.

I. EXPENSES & TAXES

I direct that all my debts, and expenses of my last illness, funeral, and burial, be paid as

soon after my death as may be reasonably convenient, and I hereby authorize my

Personal Representative, hereinafter appointed, to settle and discharge, in his or her

absolute discretion, any claims made against my estate.

I further direct that my Personal Representative shall pay out of my estate any and all

estate and inheritance taxes payable by reason of my death in respect of all items

included in the computation of such taxes, whether passing under this Will or otherwise.

Said taxes shall be paid by my Personal Representative as if such taxes were my debts

without recovery of any part of such tax payments from anyone who receives any item

included in such computation.

II. PERSONAL REPRESENTATIVE

I nominate and appoint ________________________, of

___________________________, County of ________________________, State of

______________________________ as Personal Representative of my estate and I

request that (he/she) be appointed temporary Personal Representative if (he/she)

applies. If my Personal Representative fails or ceases to so serve, then I nominate

_____________________________of __________________________, County of

____________________________, State of ______________________ to serve.

III. DISPOSITION OF PROPERTY

I devise and bequeath my property, both real and personal and wherever situated, as

follows:

Beneficiary

_______________________ [full name], currently of _______________________

[address], as my _______________________ [relation] whose last four (4) digits of their

Social Security Number (SSN) are xxx-xx-_____ with the following property:

______________________________________________________________________

Beneficiary

_______________________ [full name], currently of _______________________

[address], as my _______________________ [relation] whose last four (4) digits of their

Social Security Number (SSN) are xxx-xx-_____ with the following property:

______________________________________________________________________

Beneficiary

_______________________ [full name], currently of _______________________

[address], as my _______________________ [relation] whose last four (4) digits of their

Social Security Number (SSN) are xxx-xx-_____ with the following property:

______________________________________________________________________

If any of my beneficiaries have pre-deceased me, then any property that they would

have received if they had not pre-deceased me shall be distributed in equal shares to

the remaining beneficiaries.

If any of my property cannot be readily sold and distributed, then it may be donated to

any charitable organization or organizations of my Personal Representative’s choice. If

any property cannot be readily sold or donated, my Personal Representative may,

without liability, dispose of such property as my Personal Representative may deem

appropriate. I authorize my Personal Representative to pay as an administration

expense of my estate the expense of selling, advertising for sale, packing, shipping,

insuring and delivering such property.

IV. OMISSION

Except to the extent that I have included them in this Will, I have intentionally, and not

as a result of any mistake or inadvertence, omitted in this Will to provide for any family

members and/or issue of mine, if any, however defined by law, presently living or

hereafter born or adopted.

V. BOND

No bond shall be required of any fiduciary serving hereunder, whether or not specifically

named in this Will, or if a bond is required by law, then no surety will be required on

such bond.

VI. DISCRETIONARY POWERS OF PERSONAL REPRESENTATIVE

My Personal Representative, shall have and may exercise the following discretionary

powers in addition to any common law or statutory powers without the necessity of court

license or approval:

A. To retain for whatever period my Personal Representative deems advisable any

property, including property owned by me at my death, and to invest and reinvest in any

property, both real and personal, regardless of whether any particular investment would

be proper for a Personal Representative and regardless of the extent of diversification

of the assets held hereunder.

B. To sell and to grant options to purchase all or any part of my estate, both real

and personal, at any time, at public or private sale, for consideration, whether or not the

highest possible consideration, and upon terms, including credit, as my Personal

Representative deems advisable, and to execute, acknowledge, and deliver deeds or

other instruments in connection therewith.

C. To lease any real estate for terms and conditions as my Personal Representative

deems advisable, including the granting of options to renew, options to extend the term

or terms, and options to purchase.

D. To pay, compromise, settle or otherwise adjust any claims, including taxes,

asserted in favor of or against me, my estate or my Personal Representative.

E. To make any separation into shares in whole or in part in kind and at values

determined by my Personal Representative, with or without regard to tax basis, and to

allocate different kinds and disproportionate amounts of property and undivided

interests in property among the shares.

F. To make such elections under the tax laws as my Personal Representative shall

deem appropriate, including elections with respect to qualified terminable interest

property, exemptions and the use of deductions as income tax or estate tax deductions,

and to determine whether to make any adjustments between income and principal on

account of any election so made.

G. To make any elections permitted under any pension, profit sharing, employee

stock ownership or other benefit plan.

H. To employ others in connection with the administration of my estate, including

legal counsel, investment advisors, brokers, accountants and agents and to pay

reasonable compensation in addition to my Personal Representative’s compensation.

I. To vote any shares of stock or other securities in person or by proxy; to assert or

waive any stockholder’s rights or privilege to subscribe for or otherwise acquire

additional stock; to deposit securities in any voting trust or with any committee.

J. To borrow and to pledge or mortgage any property as collateral, and to make

secured or unsecured loans. My Personal Representative is specifically authorized to

make loans without interest to any beneficiary hereunder. No individual or entity loaning

property to my Personal Representative or trustee shall be held to see to the application

of such property.

K. My Personal Representative shall also in his or her absolute discretion determine

the allocation of any GST exemption available to me at my death to property passing

under this Will or otherwise. The determination of my Personal Representative with

respect to any elections or allocation, if made or taken in good faith, shall be binding

upon all affected.

VII. CONTESTING BENEFICIARY

If any beneficiary under this Will, or any trust herein mentioned, contests or attacks this

Will or any of its provisions, any share or interest in my estate given to that contesting

beneficiary under this Will is revoked and shall be disposed of in the same manner

provided herein as if that contesting beneficiary had predeceased me.

VIII. GUARDIAN AD LITEM NOT REQUIRED

I direct that the representation by a guardian ad litem of the interests of persons unborn,

unascertained or legally incompetent to act in proceedings for the allowance of

accounts hereunder be dispensed with to the extent permitted by law.

IX. GENDER

Whenever the context permits, the term “Personal Representative” shall include

“Executor” and “Administrator,” the use of a particular gender shall include any other

gender, and references to the singular or the plural shall be interchangeable. All

references to the Internal Revenue Code shall mean the Internal Revenue Code of

1986 or any successor Code. All references to estate taxes shall include inheritance

and other death taxes.

X. ASSIGNMENT

The interest of any beneficiary in this Will, shall not be alienable, assignable, attachable,

transferable nor paid by way of anticipation, nor in compliance with any order,

assignment or covenant and shall not be applied to, or held liable for, any of their debts

or obligations either in law or equity and shall not in any event pass to his, her, or their

assignee under any instrument or under any insolvency or bankruptcy law, and shall not

be subject to the interference or control of creditors, spouses or others.

XI. GOVERNING LAW

This document shall be governed by the laws in the State of New Jersey.

XII. BINDING ARRANGEMENT

Any decision by my Personal Representative with respect to any discretionary power

hereunder shall be final and binding on all persons interested. Unless due to my

Executor’s own willful default or gross negligence, no Executor shall be liable for said

Executor’s acts or omissions or those of any co-Executor or prior Executor.

I, the undersigned ________________________, do hereby declare that I sign and

execute this instrument as my last Will, that I sign it willingly in the presence of each of

the undersigned witnesses, and that I execute it as my free and voluntary act for the

purposes herein expressed, on this ____ day of ________________, 20____.

________________________________ ___________________________________

Testator Signature Testator (Printed Name)

The foregoing instrument, was on this ____ day of ________________, 20____,

subscribed on each page and at the end thereof by ________________________, the

above-named Testator, and by (him/her) signed, sealed, published and declared to be

(his/her) LAST WILL AND TESTAMENT, in the presence of us and each of us, who

thereupon, at (his/her) request, in (his/her) presence, and in the presence of each other,

have hereunto subscribed our names as attesting witnesses thereto.

________________________________ ___________________________________

Witness Signature Address

________________________________ ___________________________________

Witness Signature Address

TESTAMENTARY AFFIDAVIT

STATE OF ____________________

COUNTY OF __________________, SS.

Before me, the undersigned authority, on this day personally appeared

___________, testator, ____________________, witness and ___________________,

witness, known to me to be the testator and the witnesses, respectively, whose names

are signed to the attached or foregoing instrument, and, all of these persons being by

me duly sworn, the testator declared to me and to the witnesses in my presence that the

instrument is the testator’s last will and that the testator has willingly signed or directed

another to sign for him/her, and that the testator executed it as the testator’s free and

voluntary act for the purposes therein expressed; and each of the witnesses stated to

me, in the presence of the testator, that they signed the will as witnesses and that to the

best of their knowledge the testator was eighteen (18) years of age or over, of sound

mind and under no constraint or undue influence.

______________________________ ______________________________

Testator Signature Witness Signature

______________________________

Witness Signature

Subscribed and sworn to before me by the said testator and the said witnesses, this

____ day of ________________, 20____.

________________________________

Notary Public

My Commission expires:

To Whom It May Concern:

I/We, _______________________________________________________________________________

(Full Name(s) of Custodial and/or Non-Custodial Parent(s)/Legal Guardian(s))

am/are the lawful custodial parent and/or non-custodial parent(s) or legal guardian(s) of:

Child’s full name:_____________________________________________________________________

Date of Birth:________________________________________________________________________

Place of Birth:________________________________________________________________________

U.S. Passport Number:_________________________________________________________________

Date and Place of Issuance of U.S. Passport:________________________________________________

____________________________________,(Child’s Full Name) has my/our consent to travel with:

Full name of accompanying person:_______________________________________________________

U.S. or foreign passport number:_________________________________________________________

Date and Place of issuance of this passport:_________________________________________________

to travel to _____________________________________ during the period of _____________________.

During that period, _________________________________ (Child’s Name) will be residing with

____________________________________________________ at the following address:

Number/street address and apartment number:_____________________________________________

City, State/Province, Country:___________________________________________________________

Telephone and fax numbers (work, cell phone and residence)___________________________________

Parent(s) or Legal Guardian(s):

Full Name: ____________________________

Signature:_____________________________

Date:___________________

Full Name: ____________________________

Signature:_____________________________

Date:___________________

Witnesses:

Signed before me, __________________________,

this_____________________ (Date)

at ______________________. (Name of Location)

Signed before me, __________________________,

this_____________________ (Date)

at ______________________. (Name of Location)

Page 1 of 6

NEW JERSEY DURABLE POWER OF ATTORNEY

THE POWERS YOU GRANT BELOW ARE EFFECTIVE

EVEN IF YOU BECOME DISABLED OR INCOMPETENT

NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND

SWEEPING. THEY ARE EXPLAINED IN THE UNIFORM STATUTORY FORM POWER OF

ATTORNEY ACT. IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN

COMPETENT LEGAL ADVICE. THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO

MAKE MEDICAL AND OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE

THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO. THIS POWER OF

ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE TO BE EFFECTIVE EVEN

IF YOU BECOME DISABLED, INCAPACITATED, OR INCOMPETENT.

I ____________________________________________________________________________

_____________________________________________ [insert your name and address] appoint

_____________________________________________ [insert the name and address of the

person appointed] as my Agent (attorney-in-fact) to act for me in any lawful way with respect to

the following initialed subjects:

TO GRANT ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF (N) AND

IGNORE THE LINES IN FRONT OF THE OTHER POWERS.

TO GRANT ONE OR MORE, BUT FEWER THAN ALL, OF THE FOLLOWING POWERS,

INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING.

TO WITHHOLD A POWER, DO NOT INITIAL THE LINE IN FRONT OF IT. YOU MAY, BUT

NEED NOT, CROSS OUT EACH POWER WITHHELD.

Note: If you initial Item A or Item B, which follow, a notarized signature will be required on

behalf of the Principal.

INITIAL

_______ (A) Real property transactions. To lease, sell, mortgage, purchase, exchange, and

acquire, and to agree, bargain, and contract for the lease, sale, purchase, exchange, and

acquisition of, and to accept, take, receive, and possess any interest in real property whatsoever,

on such terms and conditions, and under such covenants, as my Agent shall deem proper; and to

maintain, repair, tear down, alter, rebuild, improve manage, insure, move, rent, lease, sell,

convey, subject to liens, mortgages, and security deeds, and in any way or manner deal with all

or any part of any interest in real property whatsoever, including specifically, but without limitation,

real property lying and being situated in the State of New Jersey, under such terms and

conditions, and under such covenants, as my Agent shall deem proper and may for all deferred

payments accept purchase money notes payable to me and secured by mortgages or deeds to

secure debt, and may from time to time collect and cancel any of said notes, mortgages, security

interests, or deeds to secure debt.

_______ (B) Tangible personal property transactions. To lease, sell, mortgage, purchase,

exchange, and acquire, and to agree, bargain, and contract for the lease, sale, purchase,

exchange, and acquisition of, and to accept, take, receive, and possess any personal property

whatsoever, tangible or intangible, or interest thereto, on such terms and conditions, and under

such covenants, as my Agent shall deem proper; and to maintain, repair, improve, manage,

insure, rent, lease, sell, convey, subject to liens or mortgages, or to take any other security

interests in said property which are recognized under the Uniform Commercial Code as adopted

at that time under the laws of the State of New Jersey or any applicable state, or otherwise

Page 2 of 6

hypothecate (pledge), and in any way or manner deal with all or any part of any real or personal

property whatsoever, tangible or intangible, or any interest therein, that I own at the time of

execution or may thereafter acquire, under such terms and conditions, and under such

covenants, as my Agent shall deem proper.

_______ (C) Stock and bond transactions. To purchase, sell, exchange, surrender, assign,

redeem, vote at any meeting, or otherwise transfer any and all shares of stock, bonds, or other

securities in any business, association, corporation, partnership, or other legal entity, whether

private or public, now or hereafter belonging to me.

_______ (D) Commodity and option transactions. To organize or continue and conduct any

business which term includes, without limitation, any farming, manufacturing, service, mining,

retailing or other type of business operation in any form, whether as a proprietorship, joint

venture, partnership, corporation, trust or other legal entity; operate, buy, sell, expand, contract,

terminate or liquidate any business; direct, control, supervise, manage or participate in the

operation of any business and engage, compensate and discharge business managers,

employees, agents, attorneys, accountants and consultants; and, in general, exercise all powers

with respect to business interests and operations which the principal could if present and under

no disability.

_______ (E) Banking and other financial institution transactions. To make, receive, sign,

endorse, execute, acknowledge, deliver and possess checks, drafts, bills of exchange, letters of

credit, notes, stock certificates, withdrawal receipts and deposit instruments relating to accounts

or deposits in, or certificates of deposit of banks, savings and loans, credit unions, or other

institutions or associations. To pay all sums of money, at any time or times, that may hereafter

be owing by me upon any account, bill of exchange, check, draft, purchase, contract, note, or

trade acceptance made, executed, endorsed, accepted, and delivered by me or for me in my

name, by my Agent. To borrow from time to time such sums of money as my Agent may deem

proper and execute promissory notes, security deeds or agreements, financing statements, or

other security instruments in such form as the lender may request and renew said notes and

security instruments from time to time in whole or in part. To have free access at any time or

times to any safe deposit box or vault to which I might have access.

_______ (F) Business operating transactions. To conduct, engage in, and otherwise transact

the affairs of any and all lawful business ventures of whatever nature or kind that I may now or

hereafter be involved in.

_______ (G) Insurance and annuity transactions. To exercise or perform any act, power, duty,

right, or obligation, in regard to any contract of life, accident, health, disability, liability, or other

type of insurance or any combination of insurance; and to procure new or additional contracts of

insurance for me and to designate the beneficiary of same; provided, however, that my Agent

cannot designate himself or herself as beneficiary of any such insurance contracts.

_______ (H) Estate, trust, and other beneficiary transactions. To accept, receipt for,

exercise, release, reject, renounce, assign, disclaim, demand, sue for, claim and recover any

legacy, bequest, devise, gift or other property interest or payment due or payable to or for the

principal; assert any interest in and exercise any power over any trust, estate or property subject

to fiduciary control; establish a revocable trust solely for the benefit of the principal that terminates

at the death of the principal and is then distributable to the legal representative of the estate of

the principal; and, in general, exercise all powers with respect to estates and trusts which the

principal could exercise if present and under no disability; provided, however, that the Agent may

not make or change a will and may not revoke or amend a trust revocable or amendable by the

principal or require the trustee of any trust for the benefit of the principal to pay income or

principal to the Agent unless specific authority to that end is given.

Page 3 of 6

_______ (I) Claims and litigation. To commence, prosecute, discontinue, or defend all actions

or other legal proceedings touching my property, real or personal, or any part thereof, or touching

any matter in which I or my property, real or personal, may be in any way concerned. To defend,

settle, adjust, make allowances, compound, submit to arbitration, and compromise all accounts,

reckonings, claims, and demands whatsoever that now are, or hereafter shall be, pending

between me and any person, firm, corporation, or other legal entity, in such manner and in all

respects as my Agent shall deem proper.

_______ (J) Personal and family maintenance. To hire accountants, attorneys at law,

consultants, clerks, physicians, nurses, agents, servants, workmen, and others and to remove

them, and to appoint others in their place, and to pay and allow the persons so employed such

salaries, wages, or other remunerations, as my Agent shall deem proper.

_______ (K) Benefits from Social Security, Medicare, Medicaid, or other governmental

programs, or military service. To prepare, sign and file any claim or application for Social

Security, unemployment or military service benefits; sue for, settle or abandon any claims to any

benefit or assistance under any federal, state, local or foreign statute or regulation; control,

deposit to any account, collect, receipt for, and take title to and hold all benefits under any Social

Security, unemployment, military service or other state, federal, local or foreign statute or

regulation; and, in general, exercise all powers with respect to Social Security, unemployment,

military service, and governmental benefits, including but not limited to Medicare and Medicaid,

which the principal could exercise if present and under no disability.

_______ (L) Retirement plan transactions. To contribute to, withdraw from and deposit funds

in any type of retirement plan (which term includes, without limitation, any tax qualified or

nonqualified pension, profit sharing, stock bonus, employee savings and other retirement plan,

individual retirement account, deferred compensation plan and any other type of employee

benefit plan); select and change payment options for the principal under any retirement plan;

make rollover contributions from any retirement plan to other retirement plans or individual

retirement accounts; exercise all investment powers available under any type of self-directed

retirement plan; and, in general, exercise all powers with respect to retirement plans and

retirement plan account balances which the principal could if present and under no disability.

_______ (M) Tax matters. To prepare, to make elections, to execute and to file all tax, social

security, unemployment insurance, and informational returns required by the laws of the United

States, or of any state or subdivision thereof, or of any foreign government; to prepare, to

execute, and to file all other papers and instruments which the Agent shall think to be desirable or

necessary for safeguarding of me against excess or illegal taxation or against penalties imposed

for claimed violation of any law or other governmental regulation; and to pay, to compromise, or

to contest or to apply for refunds in connection with any taxes or assessments for which I am or

may be liable.

_______ (N) ALL OF THE POWERS LISTED ABOVE. YOU NEED NOT INITIAL ANY OTHER

LINES IF YOU INITIAL LINE (N).

SPECIAL INSTRUCTIONS:

ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR

EXTENDING THE POWERS GRANTED TO YOUR AGENT.

________________________________________________________________

Page 4 of 6

________________________________________________________________

THIS POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT

IS REVOKED.

THIS POWER OF ATTORNEY SHALL BE CONSTRUED AS A GENERAL DURABLE POWER

OF ATTORNEY AND SHALL CONTINUE TO BE EFFECTIVE EVEN IF I BECOME DISABLED,

INCAPACITATED, OR INCOMPETENT.

(YOUR AGENT WILL HAVE AUTHORITY TO EMPLOY OTHER PERSONS AS NECESSARY

TO ENABLE THE AGENT TO PROPERLY EXERCISE THE POWERS GRANTED IN THIS

FORM, BUT YOUR AGENT WILL HAVE TO MAKE ALL DISCRETIONARY DECISIONS. IF YOU

WANT TO GIVE YOUR AGENT THE RIGHT TO DELEGATE DISCRETIONARY DECISION-

MAKING POWERS TO OTHERS, YOU SHOULD KEEP THE NEXT SENTENCE, OTHERWISE

IT SHOULD BE STRICKEN.)

Authority to Delegate. My Agent shall have the right by written instrument to delegate any or all

of the foregoing powers involving discretionary decision-making to any person or persons whom

my Agent may select, but such delegation may be amended or revoked by any agent (including

any successor) named by me who is acting under this power of attorney at the time of reference.

(YOUR AGENT WILL BE ENTITLED TO REIMBURSEMENT FOR ALL REASONABLE

EXPENSES INCURRED IN ACTING UNDER THIS POWER OF ATTORNEY. STRIKE OUT THE

NEXT SENTENCE IF YOU DO NOT WANT YOUR AGENT TO ALSO BE ENTITLED TO

REASONABLE COMPENSATION FOR SERVICES AS AGENT.)

Right to Compensation. My Agent shall be entitled to reasonable compensation for services

rendered as agent under this power of attorney.

(IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAME(S) AND ADDRESS(ES)

OF SUCH SUCCESSOR(S) IN THE FOLLOWING PARAGRAPH.)

Successor Agent. If any Agent named by me shall die, become incompetent, resign or refuse to

accept the office of Agent, I name the following (each to act alone and successively, in the order

named) as successor(s) to such Agent:

________________________________________________________________________

Choice of Law. THIS POWER OF ATTORNEY WILL BE GOVERNED BY THE LAWS OF THE

STATE OF NEW JERSEY WITHOUT REGARD FOR CONFLICTS OF LAWS PRINCIPLES. IT

WAS EXECUTED IN THE STATE OF NEW JERSEY AND IS INTENDED TO BE VALID IN ALL

JURISDICTIONS OF THE UNITED STATES OF AMERICA AND ALL FOREIGN NATIONS.

I am fully informed as to all the contents of this form and understand the full import of this grant of

powers to my Agent.

Page 5 of 6

I agree that any third party who receives a copy of this document may act under it. Revocation of

the power of attorney is not effective as to a third party until the third party learns of the

revocation. I agree to indemnify the third party for any claims that arise against the third party

because of reliance on this power of attorney.

Signed this _______ day of _______________, 20____

______________________________

[Your Signature]

_______________________________

[Your Social Security Number]

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

STATE OF NEW JERSEY

COUNTY OF ________________

This document was acknowledged before me on _______________ [Date] by

________________________________________________ [name of principal].

[Notary Seal, if any]:

_______________________________

(Signature of Notarial Officer)

Notary Public for the State of New Jersey

My commission expires: ___________________

ACKNOWLEDGMENT OF AGENT

BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES THE

FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.

________________________________________________

[Typed or Printed Name of Agent]

________________________________________________

[Signature of Agent]

Page 6 of 6

PREPARATION STATEMENT

This document was prepared by the following individual:

________________________________________________

[Typed or Printed Name]

________________________________________________

[Signature]

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

The New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care

Page 1 of 2

PROXY DIRECTIVE--(Durable Power of Attorney for Health Care)

Designation of Health Care Representative

I understand that as a competent adult, I have the right to make decisions about my health care. There may

come a time when I am unable, due to physical or mental incapacity, to make my own health care decision. In

these circumstances, those caring for me will need direction and they will turn to someone who knows my values

and health care wishes. By writing this durable power of attorney for health care I appoint a health care

representative with the legal authority to make health care decisions on my behalf and to consult with my

physician and others. I direct that this document become part of my permanent medical records.

A) CHOOSING A HEALTH CARE REPRESENTATIVE:

I, ______________________________, hereby designate _________________________________________,

of _________________________________________________________________________________________

___________________________________________________________________________________________,

(home address and telephone number of health care representative)

as my health care representative to make any and all health care decisions for me, including decisions to accept or

to refuse any treatment, service or procedure used to diagnose or treat my physical or mental condition and

decisions to provide, withhold or withdraw life-sustaining measures. I direct my representative to make decisions

on my behalf in accordance with my wishes as stated in this document, or as otherwise known to him or her. In

the event my wishes are not clear, my representative is authorized to make decisions in my best interest, based on

what is known of my wishes.

This durable power of attorney for health care shall take effect in the event I become unable to make my own

health care decisions, as determined by the physician who has primary responsibility for my care, and any

necessary confirming determinations.

B) ALTERNATE REPRESENTATIVES: If the person I have designated above is unable, unwilling or

unavailable to act as my health care representative, I hereby designate the following person(s) to act as my health

care representative, in the order of priority stated:

1. name ________________________________ 2. name ________________________________

address ______________________________ address ______________________________

city _____________________ state _______ city ______________________ state _______

telephone ____________________________ telephone _____________________________

C) SPECIFIC DIRECTIONS: Please initial the statement below which best expresses your wishes.

_____ My health care representative is authorized to direct that artificially provided fluids and nutrition,

such as by feeding tube or intravenous infusion, be withheld or withdrawn.

_____ My health care representative does not have this authority, and I direct that artificially provided

fluids and nutrition be provided to preserve my life, to the extent medically appropriate.

The New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care

Page 2 of 2

(If you have any additional specific instructions concerning your care you may use the space below or attach an

additional statement.)

___________________________________________________________________________________________

D) COPIES: The original or a copy of this document has been given to my health care representative and to the

following:

1. name ___________________________________

address _________________________________

city ________________________ state _______ telephone __________________________

2. name ___________________________________

address _________________________________

city ________________________ state _______ telephone __________________________

E) SIGNATURE: By writing this durable power of attorney for health care, I inform those who may become

entrusted with my care of my health care wishes and intend to ease the burdens of decision making which this

responsibility may impose. I have discussed the terms of this designation with my health care representative and

he or she has willingly agreed to accept the responsibility for acting on my behalf in accordance with my wishes

as expressed in this document. I understand the purpose and effect of this document and sign it knowingly,

voluntarily and after careful deliberation.

Signed this _____________ day of ______________, 20______.

signature _____________________________________________

address ______________________________________________

city ____________________________________ state_________

F) WITNESSES: I declare that the person who signed this document, or asked another to sign this document on

his or her behalf, did so in my presence, that he or she is personally known to me, and that he or she appears to be

of sound mind and free of duress or undue influence. I am 18 years of age or older, and am not designated by this

or any other document as the person’s health care representative, nor as an alternate health care representative.

1. witness____________________________________ 2. witness _______________________________

address ___________________________________ address ______________________________

city _______________________ state __________ city ____________________ state _________

signature _________________________________ signature _____________________________

date ______________________________________ date _________________________________

City of Kansas City, Mo.

Neighborhood and Community Services Department

Tow Services Division

7750 E. Front St.

Kansas City, MO 64120

(816) 513-1313

Authorization to release/view vehicle

This form must be signed by the owner/operator in the presence of a notary public in order to be valid

I, _________________________________________, hereby authorize the employees of the City of Kansas City,

Owner/operator of the vehicle

Mo., Tow Services Division to release/allow to view (circle one) my ________ ______________________

Year Make

vehicle with #_________________ on __________________ plates and #________________________________,

License plate number State Vehicle identification number

impounded on __________________ to _________________________________________.

Date Representative of the owner/operator of the vehicle

I have duly authorized the aforementioned party as my representative to take possession of or view the said vehicle

and to pay any charges or fees for towage, storage or impoundment accruing on said vehicle. The aforementioned

representative may also take possession of any property removed from this vehicle and stored at the vehicle

impound facility.

Executed by ___________________________________________ on __________________

Signature of owner/operator of the vehicle Date

____ ____________________________________________

Signature of representative of the owner/operator of the vehicle

____ ____________________________________________

Printed name

____ _________________________________________________________

Street, city, state and ZIP code

Before me, the undersigned authority, _________________________________________ personally appeared and

Owner/operator of the vehicle

stated to me, under oath, that he is the owner and/or operator of the aforementioned vehicle stored at the City of

Kansas, Mo., vehicle impound facility.

Given under my hand and seal of this office on __________________, I, __________________________________,

Date Signature of notary public

a notary public for ______________________ County in the state of ______________________

County State

TOW NO.

Revised Jan13

AUTENTICA DI FOTO – MINORI DI ANNI 12

Authentication of photograph – For children 11 years of age and under

Incollare qui una delle due foto

Attach one photograph here

verificare che la foto corrisponda alla normativa

visionare le istruzioni generali sul sito

verify that the photograph matches the applicant

refer to the general instructions on our website

Il sottoscritto (cognome e nome)___________________________________________

the undersigned (last name, name)

nello svolgimento delle mie funzioni di: in the execution of my duties as:

Console onorario / corrispondente consolare / “Notary Public” (Honorary Consul,

Consular Corrispondent, Notary Public) (sottolineare quanto corrispondente al proprio

ruolo – underline the correct title)

e dopo aver visto il minore (cognome, nome, data di nascita):

_______________________________________________________________________

and after have seen the minor child (last name, first name, date of birth)

presentatosi DI PERSONA dinanzi a me in data odierna - PERSONALLY PRESENTED TO

ME ON THIS DATE

accompagnato dal genitore

(cognome e

nome

):________________________________

accompanied by his/her parent (last name and first name)

DICHIARA /DECLARES

che la foto su incollata riporta le fattezze del minore su citato – that the above-attached

photo matches the features of the minor child presented to me today.

Luogo e data ___________________________________________

Place and date

Firma e timbro del dichiarante

Signature and seal of the declarant

IRREVOCABLE ASSIGNMENT

Insured/Deceased__________________________________ Beneficiary__________________________

Insurance Company _____________________________________________ and its successors or assigns

Policy Number(s) ______________________________________________________________________

Funeral Home/Cemetery ________________________________________________________________

Assignment Amount $ _____________________________________________________ ( ).

This Irrevocable Assignment is made between Beneficiary above and the Funeral Home above. In consideration for

the Funeral Home providing services in the burial of the above Insured, said services having requested and accepted

by Beneficiary and/or additional funds have been advanced to Beneficiary, the undersigned irrevocably assigns to

Funeral Home or its assigns, the above Assignment Amount, plus statutory interest from deceased’s date of death

until claim paid and plus unearned premiums. Beneficiary hereby guarantees the validity and sufficiency of the

foregoing irrevocable assignment to the Funeral Home or its assigns, and Beneficiary further guarantees to warrant

title to the policy(s) and defend Funeral Home or its assigns against any claims on the policy(s). Beneficiary hereby

irrevocably authorizes said Insurance Company to make payment of the sum specified above, plus statutory interest

and unearned premiums to the Funeral Home or its assigns. In addition, Beneficiary hereby irrevocably authorizes

said Insurance Company to give Funeral Home or its assigns any information that it may require regarding said

policy(s). Beneficiary hereby appoints Funeral Home or its assigns as their Attorney-in-fact and to act on their

behalf with regard to the collection of, settlement of, and receipt of proceeds of said policy(s) or certificate(s),

including but not limited to, giving Funeral Home or its assigns the right to endorse checks, sign and submit

claimant statement forms. Beneficiary further acknowledges that this assignment may be reassigned. As such, if for

any reason it becomes necessary to proceed against the Beneficiary or the Funeral Home, it is hereby agreed that

each are jointly and severally liable for all costs of collections, including but not limited to, reasonable attorney’s

fees, and court costs. In the event the policy(s) is not enclosed, I certify that the policy(s) has been lost or destroyed.

1) Beneficiary Signature ___________________________________________

Relationship to Deceased ______________________ Beneficiary’s SS# _______________________

Date of Birth_______________________ (must be 18) Telephone #__________________________

Address______________________________________________________________________________

City/State/Zip_________________________________________________________________________

2) Beneficiary Signature ___________________________________________

Relationship to Deceased ______________________ Beneficiary’s SS# _______________________

Date of Birth_______________________ (must be 18) Telephone #__________________________

Address______________________________________________________________________________

City/State/Zip_________________________________________________________________________

3) Beneficiary Signature ___________________________________________

Relationship to Deceased ______________________ Beneficiary’s SS# _______________________

Date of Birth_______________________ (must be 18) Telephone #__________________________

Address______________________________________________________________________________

City/State/Zip_________________________________________________________________________

The foregoing Assignment was executed by______________________________________________,

who are ( ) personally known to me or ( ) who have produced identification.

NOTARY PUBLIC SIGNATURE _______________________________ DATE ___________________

Limited Power of Attorney

For Title and Federal Odometer Disclosure Statement

I, ____________________________________________,

the undersigned authorized Owner

and _________________________________________

, the undersigned authorized Co-owner,

(Name of Co-Owner, if applicable)

having a residence or place of business at _______________________________________, do

hereby grant unto Volkswagen Group of America, Inc. Power of Attorney to act on behalf of the

individual, company, firm or corporation named above

 In all matters concerning the transfer of certificate of title for

____________________________, a motor vehicle owned or sold by

the said individual,

company, firm or corporation, and

 In signing of the Federal Odometer Disclosure Statement, and

 In the recovery of sales tax for the repurchased vehicle.

This

Power of Attorney is executed on _______________________, 20______.

I hereby certify that the statements made herein are true and correct to the best of my knowledge,

information and belief.

I also hereby certify that as of this date, I no longer have possession of or any interest in the above

referenced vehicle.

Note

: Stamped Signatures or Copies of Signatures are Not Acceptable

Signature of individual(s) or representative granting Power of Attorney

Co-Owner Signature, if applicable

not sign below this line

For internal use only

By:

Volkswagen Group of America, Inc.

Signature and address of person granted Power of Attorney 3800 Hamlin Road

Auburn Hills, MI 48326

In The Presence Of (Notary Public to stamp below)

The information collected on this form is used in conjunction with the DS-11, "Application for a U.S. Passport." When a minor under the age

of 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 completed

and notarized DS-3053 can be used as the statement of consent. If the required statement is not submitted, the minor may not be eligible to

receive a U.S. passport. The required statement may be submitted in other formats provided they meet statutory and regulatory

requirements.

USE OF THIS FORM

DS-3053 08-2016 Page 1 of 2

For passport and travel information, please visit our website at travel.state.gov. 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 NPIC@state.gov

. Customer Service Representatives are available

Monday-Friday, 8:00 a.m. - 10:00 p.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 PreventAbduction1@state.gov

1. Complete fields 1, 2, and 3. If field 3 is not completed, authorization will be valid for both products.

2. Complete field 4, Statement of Consent, only if you are a non-applying parent or guardian consenting to the issuance of a passport for your minor

child. NOTE: Your signature must be witnessed and notarized in field 5.

3. The written consent from the non-applying parent that accompanies an application for a new U.S. passport must not be more than 90 days old.

A clear photocopy of the front and back of the non-applying parent's government-issued photo identification presented to the notary is required

with the written consent.

4. Please submit this form with your minor child's new DS-11 passport application to any designated acceptance facility, U.S. Passport Agency, U.S.

Embassy, or U.S. Consulate abroad.

STATEMENT OF CONSENT:

ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16

FORM INSTRUCTIONS

WARNING: 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.

FOR INFORMATION AND QUESTIONS

U.S. Department of State

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time required for searching

existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection. 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 Legal Affairs and Law Enforcement Liaison, Attn: Forms Officer 44132 Mercure Cir, P.O. Box 1227, Sterling, Virginia 20166-1227.

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 the information is to establish two parent consent for a minor's passport application, as required by

Public Law 106-113, Section 236.

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.

Below is a list of documents you must submit with your DS-3053:

1. A c

ertified order of a court of competent jurisdiction granting guardianship to the institution/entity. (Photocopies are not acceptable.)

2. A signed statement from the institution/entity on letterhead authorizing a specific person to apply for a passport for the child on its behalf. The

statement must include the minor's name and the name of the individual(s) authorized to apply for the passport.

3. A photocopy of employee identification documents proving the person applying for the minor's passport works at the institution/entity.

SPECIAL REQUIREMENTS FOR INSTITUTIONS/ENTITIES GRANTED GUARDIANSHIP

PAPERWORK REDUCTION ACT STATEMENT

PRIVACY ACT STATEMENT

Please ensure that all of the above do NOT have any conditions placed on the period of validity of the passport or where the minor may travel. If there

are conditions in the statement, a new statement of unequivocal consent is required.

Passport Book and Card

3. THIS AUTHORIZATION IS VALID FOR:

to apply for a United States passport for my minor child named on this application. My consent is unconditional in regards to passport validity and travel.

STOP! YOU MUST SIGN THIS FORM IN FRONT OF A NOTARY.

2. MINOR'S DATE OF BIRTH

First Middle

(mm/dd/yyyy)

Last

4. STATEMENT OF CONSENT To be completed by the non-applying parent or guardian using his/her information when not

present at the time the applying parent or guardian submits the minor's application. Statements expire after 90 days.

1. MINOR'S NAME

OATH: I declare under penalty of perjury that all statements made in this supporting document are true and correct.

Date (mm/dd/yyyy)Signature of Non-Applying Parent or Guardian

5. STATEMENT OF CONSENT NOTARIZATION

Name of Notary

Location

City, State

Commission Expires

Date (mm/dd/yyyy)

Signature of Notary

NOTARY

SEAL

Date of

Notarization

Date (mm/dd/yyyy)

Identification Presented

by Non-Applying Parent or

Guardian:

Passport Military IDDriver's License Other (specify)

Issue Date (mm/dd/yyyy):

Place of Issue:ID Number:

STATEMENT OF CONSENT:

ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16

OMB CONTROL NO. 1405-0129

OMB EXPIRATION DATE: 08-31-2019

ESTIMATED BURDEN: 20 Minutes

DS-3053 08-2016

Page 2 of 2

Attention: Read WARNING and FORM INSTRUCTIONS on Page 1

NOTE

: A clear photocopy of the front and back of the identification you presented to the notary is required with this form.

Expiration Date (mm/dd/yyyy):

OATH: By signing this document, I certify that I am a licensed notary under laws and regulations of the state or country for which I am

performing my notarial duties, that I am not related to the above affiant, that I have personally witnessed him/her sign this document, and

that I have properly verified the identity of the affiant by personally viewing the above notated identification document and the matching

photocopy.

Street Address (non-applying parent)

Apartment Zip CodeStateCity

Telephone Number E-mail Address

U.S. Department of State

( )

Area Code

Print Name (non-applying parent/guardian)

Print Name (Notary Public)

authorize

Print Name (person applying for minor's passport)

Book Only Card Only

Page 1 of 2

U.S. Department of State

STATEMENT OF CONSENT:

ISSUANCE OF A U.S. PASSPORT TO A CHILD

OMB CONTROL NO. 1405-0129

EXPIRES: 12-31-2023

Estimated Burden: 20 minutes

DS-3053 12-2020

USE OF THIS FORM

This form is used when one or both legal parents and/or legal guardians cannot apply in person with the child for that child's

passport. The legal parent/legal guardian who cannot apply with the child can give consent using this form or a written statement that

includes all of the information on this form. This form or the written statement must be notarized. If the required consent is not

submitted, the child may not be eligible for a U.S. passport.

 For children under the age of 16: Both legal parents/legal guardians must apply for the passport with the child or the legal

parent/legal guardian that cannot apply with the child must complete and notarize this form to be submitted with the

application.

 For children 16 or 17 years old: The Department may request the consent of one legal parent/legal guardian to the issuance

of a passport to an applicant who is 16 or 17 years of age. In many cases, the passport authorizing officer may be able to

ascertain parental awareness of the application by virtue of the parent’s presence when the minor submits the application or

a signed note from the parent or proof the parent is paying the application fees. However, the passport authorizing officer

retains discretion to request the legal parent’s/legal guardian’s notarized statement of consent to issuance (e.g., on Form

DS-3053).

IMPORTANT

• If #3 on page two is not completed, consent will be valid for both passport book and card.

• Statements of consent expire 90 days after the date of notarization.

• You must submit a photocopy of the front and back of the identification you presented to the notary.

• You must sign the statement of consent in front of a notary.

• The date of the notary's signature must be the same as the date of your signature.

• This form can also be used to authorize a third party to apply for a child's passport on behalf of the legal parents/legal

guardians who cannot apply in person.

INSTITUTIONS/ENTITIES GRANTED GUARDIANSHIP

You must submit all of the following with this form:

1. A certified court order granting guardianship to the institution/entity. Photocopies are not acceptable.

2. A signed statement from the institution/entity on letterhead authorizing a specific person to apply for a passport for the child

on the child's behalf.

The statement must include the child's name and the name of the individual(s) authorized to apply for the passport.

3. A photocopy of employee identification documents proving the person applying for the child's passport works at the

institution/entity.

Please ensure that none of the above documents has any conditions placed on the period of validity of the passport or where the

child may travel. If there are conditions in the statement, a new statement of consent is required.

WARNING

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.

FOR INFORMATION AND QUESTIONS

For passport and travel information, please visit travel.state.gov. In addition, contact the National Passport Information Center

(NPIC) toll-free at 1-877-487-2778 (TDD/TTY 1-888-874-7793) or by email at NPIC@state.gov. For information on International

Parental Child Abduction, please visit travel.state.gov/childabduction or contact the Office of Children's Issues by telephone at

1-888-407-4747 or by email at PreventAbduction1@state.gov.

PRIVACY ACT STATEMENT

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 the information is to establish two-parent consent for applicants under the age of 16 or

one-parent consent, when requested by the Department, for applicants age 16 or 17, consistent with Public Law 106-113, Section

236.

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-26,

Passport Records, and State-05, Overseas Citizen Services Records and Other Overseas Records.

DISCLOSURE: Failure to provide the information requested on this form may result in the refusal or denial of a U.S. passport

application.

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time required

for searching existing data sources, gathering the necessary data, providing the information and/or documents required, and

reviewing the final collection. 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, Attn: Forms Officer, 44132 Mercure Cir, PO Box 1199, Sterling, Virginia 20166-1199.

Please Print Legibly Using Black Ink Only. If you make an error, complete a new form. Do not correct.

Page 2 of 2

U.S. Department of State

STATEMENT OF CONSENT:

ISSUANCE OF A U.S. PASSPORT TO A CHILD

OMB CONTROL NO. 1405-0129

EXPIRES: 12-31-2023

Estimated Burden: 20 minutes

DS-3053 12-2020

1. CHILD’S NAME (As it appears on form DS-11, Application for a U.S. Passport)

Last

First

Middle

2. CHILD’S DATE OF BIRTH (mm/dd/yyyy)

3. THIS CONSENT IS VALID FOR A:

Passport Book and Card Book Only Card Only

4a. IS CHILD UNDER 16 YEARS OLD?

4b. IF YES, PRINT NAME OF ADULT APPLYING WITH CHILD

Yes No

5. STATEMENT OF CONSENT To be completed by the legal parent/legal guardian who cannot apply with the child. The legal

parent/legal guardian who cannot apply with the child must complete the information below. This statement expires 90 days after the

date of notarization.

, give my consent to the issuance of a United States passport to the minor child

Print Name of Legal Parent/Legal Guardian

(who cannot apply in person with the child)

named on this application. My consent is unconditional with regards to passport validity and travel.

Street Address

Apt#

City

State

Zip Code

( )

Area Code

Telephone Number

Email Address

STOP! YOU MUST SIGN AND DATE BELOW IN FRONT OF A NOTARY.

OATH: I declare under penalty of perjury that all statements made in this supporting document are true and correct.

Signature of Legal Parental/Legal Guardian (who cannot apply in person with the child)

Date (mm/dd/yyyy)

IMPORTANT: You must submit a clear photocopy of the front and back of the identification you presented to the notary. The date

you sign the form must be the same date that the notary signs the form.

6. FOR COMPLETION BY NOTARY

On the date specified above and below, the affiant listed above, who is not related to me, personally appeared before me and is

known to me to be the person whose name is subscribed to and acknowledged that he/she executed the same for the uses and

purposes therein contained. I have properly verified the identity of the affiant by personally viewing the below notated identification

document and matching photocopy.

Name of Notary

Print Name (Notary Public)

Location

City, State

Commission Expires

NOTARY

SEAL

Date (mm/dd/yyyy)

Identification Presented by Legal

Parent/Legal Guardian: (who cannot

apply in person with the child)

Driver’s License Passport Military ID Other (specify)

Legal Parent/Legal Guardian ID

Number:

Place of Issue:

Issue Date (mm/dd/yyyy):

Expiration Date (mm/dd/yyyy):

Signature of Notary

Date of Notarization:

Please Print Legibly Using Black Ink Only. If you make an error, complete a new form. Do not correct.

RESET

click to sign

signature

click to edit

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Vzgq0d BoQ0u Hj2yquOKQ New Jersey Real World Notary Training Docs (City of Oakland)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Vzgq0d BoQ0u Hj2yquOKQ New Jersey Real World Notary Training Docs (City of Oakland) Form

Related forms

Fillable Vzgq0d BoQ0u Hj2yquOKQ New Jersey Real World Notary Training Docs (City of Oakland)

Fill Online, Printable, Fillable, Blank Vzgq0d BoQ0u Hj2yquOKQ New Jersey Real World Notary Training Docs (City of Oakland) Form

Related forms

First 20 documents completely FREE!