Fill and Sign the Syllabus Edci 63006162 Spring 2012 the University of Texas at Utb Form

U. S. Department of State OMB NO. 1405-0076 EXPIRES 09-30-2006 Estimated Burden - 1 Hour* APPLICATION FOR ASSISTANCE UNDER THE HAGUE CONVENTION ON INTERNATIONAL CHILD ABDUCTION FILL OUT ALL SECTIONS ON BOTH SIDES A SEPARATE FORM IS REQUIRED FOR EACH CHILD RETURN Application for: ACCESS I. IDENTITY OF CHILD AND PARENTS DATE OF BIRTH (mm-dd-yyyy) PLACE OF BIRTH CHILD'S NAME (Last, First, MI) ADDRESS (At time of removal) U.S. SOCIAL SECURITY NO. PASSPORT/IDENTITY CARD NATIONALITIES COUNTRY: NO. HEIGHT SEX WEIGHT Male COLOR OF HAIR COLOR OF EYES Female FATHER MOTHER NAME (Last, First, MI) NAME (Last, First, MI) DATE OF BIRTH (mm-dd-yyyy) NATIONALITIES PLACE OF BIRTH OCCUPATION PASSPORT/IDENTITY CARD DATE OF BIRTH (mm-dd-yyyy) NATIONALITIES PLACE OF BIRTH OCCUPATION PASSPORT/IDENTITY CARD COUNTRY: COUNTRY: NO. NO. CURRENT ADDRESS AND TELEPHONE NUMBER CURRENT ADDRESS AND TELEPHONE NUMBER U.S. SOCIAL SECURITY NO. U.S. SOCIAL SECURITY NO. COUNTRY OF HABITUAL RESIDENCE COUNTRY OF HABITUAL RESIDENCE DATE AND PLACE OF MARRIAGE, IF APPLICABLE (mm-dd-yyyy) DATE AND PLACE OF DIVORCE, IF APPLICABLE (mm-dd-yyyy) II. PERSON SEEKING RETURN OF/ACCESS TO CHILD NATIONALITIES NAME (Last, First, MI) RELATIONSHIP TO CHILD OCCUPATION CURRENT ADDRESS AND TELEPHONE NUMBER NAME, ADDRESS, AND TELEPHONE NO. OF LEGAL ADVISER, IF ANY III. INFORMATION CONCERNING THE PERSON ALLEGED TO HAVE WRONGFULLY REMOVED OR RETAINED CHILD NAME (Last, First, MI) RELATIONSHIP TO CHILD KNOWN ALIASES DATE OF BIRTH (mm-dd-yyyy) PLACE OF BIRTH OCCUPATION, NAME AND ADDRESS OF EMPLOYER NATIONALITIES PASSPORT/IDENTITY CARD U.S. SOCIAL SECURITY NO. COUNTRY: NO. CURRENT LOCATION HEIGHT WEIGHT COLOR OF HAIR COLOR OF EYES *SEE PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS ON REVERSE DS-3013 (Formerly DSP-105) 10-2003 Page 1 of 2 ADDITIONAL SHEETS MAY BE ATTACHED OTHER PERSONS WITH POSSIBLE ADDITIONAL INFORMATION RELATING TO THE WHEREABOUTS OF CHILD (Name, address, telephone number) IV. TIME, PLACE, DATE, AND CIRCUMSTANCES OF THE WRONGFUL REMOVAL OR RETENTION V. FACTUAL OR LEGAL GROUNDS JUSTIFYING THE REQUEST VI. CIVIL PROCEEDINGS IN PROGRESS, IF ANY VII. CHILD IS TO BE RETURNED TO DATE OF BIRTH (mm-dd-yyyy) PLACE OF BIRTH NAME (Last, First, MI) ADDRESS TELEPHONE NUMBER PROPOSED ARRANGEMENTS FOR RETURN TRAVEL OF CHILD VIII. OTHER REMARKS SIGNATURE OF APPLICANT (sign in blue ink) DATE (mm-dd-yyyy) PLACE PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS This information solicited on this form is requested under the authority of the International Child Abduction Remedies Act, Public Law 100-300. 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. The principal users of this information are offices within the U.S. Department of State's Bureau of Consular Affairs. The information will be used to assist infacilitating 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. Furnishing your social security number, as well as the other information requested on this form, is voluntary. However, failure to submit this form or to provide all the requested information may result in delay in the processing of your application. *Public reporting burden for this collection of information is estimated to average1hour 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: U.S. Department of State (A/RPS/DIR), 1800 G Street, Washington, DC 20520. DS-3013 Page 2 of 2