PRIVACY ACT STATEMENT
PAPERWORK REDUCTION ACT STATEMENT
*Public reporting burden for this collection of information is estimated to average 60 minutes
per response, including time required for searching existing data sources, gathering the
necessary data, providing the information required, and reviewing the final collection. You do
not have to provide this information requested if the OMB approval has expired. Send
comments on the accuracy of this estimate of the burden and recommendations for reducing it
to: CA/OCS/L, SA-29, 4th Floor, U.S. Department of State, Washington, DC 20037-3202.
AUTHORITY: The information solicited on this form is requested under the authority of the
International Child Abduction Remedies Act, Public Law 100-300, codified at 22 U.S.C. 9001 et.
PURPOSE: The primary purpose for soliciting the information is to evaluate applicants' claims
under the Hague Convention on the Civil Aspects of International Child Abduction, advise
applicants about available legal remedies, and locate abducted children.
Furnishing your social security number, as well as the other information requested on this form,
is voluntary. The social security number may be used, if necessary, to authenticate the
identities of individuals that are listed in the applicant claim.
ROUTINE USES: The information will be used to assist in facilitating operations under the
Convention and may be provided to governments of member countries, bar associations and
legal aid services, local police, social service agencies, and parents. This information may also
be released on a need-to-know basis to other government agencies, including foreign agencies,
having statutory or other lawful authority to gain access to such information. More information
on the Routine Uses for the system can be found in the System of Records Notice State-05,
Overseas Citizens Services Records.
DISCLOSURE: Providing the information requested on this form, including the child's social
security number, is voluntary. Failure to submit this form or to provide all the requested
information may result in delay in the processing of your application.
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