U.S. SSN*
Weight
Known Aliases
Date of Birth (mm-dd-yyyy)
Color of Hair
U.S. SSN*
Passport/Identity Card*
Passport/Identity Card*
Citizenship(s)
U. S. Department of State
DS-3013
07-2017
II. APPLICANT (PERSON SEEKING RETURN OF/ACCESS TO CHILD/CHILDREN)
Name (Last, First, MI)
Relationship to Child/ren
Place of Birth
Number
Date of Birth (mm-dd-yyyy)
APPLICATION UNDER THE HAGUE CONVENTION ON THE CIVIL
ASPECTS OF INTERNATIONAL CHILD ABDUCTION
Return of Access to
This is an application for the
FILL OUT ALL SECTIONS ON BOTH SIDES
*Provide information below to the extent that it is available.
OMB NO. 1405-0076
EXPIRES: 04-30-2019
Estimated Burden - 1 Hour*
Page 1 of 5
the child/children listed below.
Citizenship(s)
Occupation
III. PERSON ALLEGED TO HAVE WRONGFULLY REMOVED OR RETAINED THE CHILD/CHILDREN
Name (Last, First, MI)
Relationship to Child/ren
Place of Birth
Number
Date of Birth (mm-dd-yyyy)
Country
U.S. SSN*
Height Weight
Color of Hair
Color of Eyes
(If Known)
Current Address, Telephone Number, and Email Address
I. FIRST CHILD SUBJECT OF APPLICATION
Name of Child's Mother if not Listed in Section II or III3
Passport/Identity Card*
Place of Birth
Height Color of Eyes
Number
Country
Name of Child's Father if not Listed in Section II or III
(At Time of Removal)
(If Known)
Address and Telephone Number of Child's Current Location
Address
Name, Address, and Telephone Number of Legal Advisor*
Occupation, Name, and Address of Employer
Address and Telephone Number of Current Location
Child's Name
(Last, First, MI.)
Citizenship(s)
Country
Citizenship(s)
U.S. SSN*
Passport/Identity Card*
Child's Name (Last, First, MI)
Name of Child's Father if not Listed in Section II or III
Passport/Identity Card*
Passport/Identity Card*
Child's Name (Last, First, MI)
Date of Birth (mm-dd-yyyy)
Place of Birth
Height
Weight
Color of Hair
Color of Eyes
Number
Country
Citizenship(s)
Name of Child's Father if not Listed in Section II or III
Name of Child's Mother if not Listed in Section II or III
Page 2 of 5
Passport/Identity Card*
Child's Name (Last, First, MI)
Date of Birth (mm-dd-yyyy)
Place of Birth
Height
Weight
Color of Hair
Color of Eyes
Number
Country
U.S. SSN*
Citizenship(s)
Name of Child's Father if not Listed in Section II or III
Name of Child's Mother if not Listed in Section II or III
Date of Birth (mm-dd-yyyy)
Place of Birth
Height Weight
Color of Hair
Color of Eyes
Number
Country
U.S. SSN*
Citizenship(s)
Name of Child's Father if not Listed in Section II or III
Name of Child's Mother if not Listed in Section II or III
(If Known)
(If Known)
Name of Child's Mother if not Listed in Section II or III
IV. ADDITIONAL CHILD/CHILDREN Subject of Application
Child's Name (Last, First, MI)
Date of Birth (mm-dd-yyyy)
Place of Birth
Height
Weight
Color of Hair
Color of Eyes
Number
Country
(At Time of Removal)
DS-3013
Address
Address and Telephone Number of Child's Current Location
Address (At Time of Removal)
Address
(At Time of Removal)
Address and Telephone Number of Child's Current Location
U.S. SSN*
(At Time of Removal)Address
Address and Telephone Number of Child's Current Location (If Known)
Address and Telephone Number of Child's Current Location (If Known)
DS-3013
ADDITIONAL SHEETS MAY BE ATTACHED
VI. FACTUAL AND LEGAL JUSTIFICATION FOR THE REQUEST
Are civil proceedings currently in progress? (If yes, please provide details.)
Page 3 of 5
Basis of Applicants' Custody Rights
Law/Statute of Child's Residence at Time of Alleged Removal or Retention
Court Order in Effect at Time of Alleged Removal or Retention
Legally Binding Agreement
Marriage Certificate, If Applicable
Child's Birth Certificate, Required
Other
V. TIME, PLACE, DATE AND CIRCUMSTANCES OF THE WRONGFUL REMOVAL OR RETENTION
Additional sheets may be attached.
Supporting Documentation
(Please check applicable boxes and attach.)
Habitual Residence
(Please provide details related to the child's place of habitual residence.)
IX. OTHER RELEVANT INFORMATION
DS-3013
ADDITIONAL SHEETS MAY BE ATTACHED
VII. PROPOSED ARRANGEMENTS FOR RETURN TRAVEL OF CHILD/CHILDREN
VIII. OTHER PERSONS WITH ADDITIONAL INFORMATION RELATING
TO THE WHEREABOUTS OF THE CHILD/CHILDREN
Preferably, in country of child's current location. Please include, name, address, telephone number, and /or email address.
Page 4 of 5
Applicant Signature (Sign in Blue Ink) Date (mm-dd-yyyy)
Signing Instructions
click to sign
signature
click to edit
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.
seq..
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.
DS-3013
Page 5 of 5
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