Please carefully read the information below before completing this Letter of Authorization.
An individuals personal information cannot be released by the U.S. government to another party without the
written consent of the individual under the provisions of the Privacy Act of 1974 (5 USC 552a). As a result, an
employee at a U.S. passport agency cannot discuss the details of your passport application with a third party
without your written consent.
Please check all that apply:
(Note: All of the information below may ONLY be filled out by the applicant, parent, legal guardian, or
person legally acting in loco parentis)
Name : ______________________________________________________
(Last Name, First Name, Middle Name)
Phone Number: ________________________ Date____________________________
(If the applicant is under the age of 16 the parent(s),legal guardian(s), or person legally acting in loco parentis