HomeMy WebLinkAboutContract 49765-FP1 FORT WO RT Ho
NOTICE OF PROJECT COMPLETION
(Developer Projects)
The Transportation and Public Works Department upon the recommendation of the Project
Manager has accepted the following project as complete*
Project Name: S& B TECHNICAL PRODUCTS
Improvement Type(s). 4 Water J Sewer
City Project No.: 101132
Original Contract Price, $146005.50
Amount of Approved Change Order(s): $ 27689.00
Revised Contract Amount: $173694.50
dotal Cost of Work Complete.- $173694.50
01/25/2018
Contractor Date
Vice President
Title
Walker Utilities Inc.
Company Name
%ufgk 7-d&&&&gm 01/25/2018
I jsllws I W.'Amn;Jn 25. Ott
Project Inspector Date
2aLvf�,7. W
[Il&,ft&_ 01/25/2018
Ppiect Manager Date
01/25/2018
CFA Manager Date
01125/2018
Asst. City Manager Date
Pag
OFFICIAl. A'CORD
CITY SECRETARY
FT.WORTH,TX
Notice of Project Completion
Project Name: S & B TECHNICAL PRODUCTS
City Project No,: 101132
City's Attachments
Original Unit Price Bid Proposal
Change Order(s): �I
Pipe Report: q
Acceptance Letter
Contractor's Attachments
Affidavit of Bills Paid
Consent of Surety J
Statement of Contract Time
Contract Time: 70 CD Days Charged: 72
Work Start Date: 10/30/2.011 Work Cornplele Date: 01/119/20118
Page 2 of 2
FORT WORTH
CITY OF FORT WORTH
FINAL PAYMEN'11ZE QUEST
Contract Name S&B TECHNICAL PRODUCTS
Conti-act Limits
Project Type WATER&SEWER
City Project Numbers 101132
DOE Number 1132
Estimate Number i Payment Number I For Period Ending 1/1612018
CD
City See,et,jj y attract Numbc.- Contract Time 7(TD
Contract Date 10/612017 Days Charged to Date 72
Contrart is 100-00 Complete
Project Manager NA
Contractor WALKER UTILITIES,INC.
P.O.BOX 54122
HURST, TX 76054
Inspectors ROLLS MCKJNNON
iI
Page I of 5
Wednesday,January 24,2018
City Project Numbers 101132 DOE Number 1132
Contract Name S&D TECHNICAL PRODUCTS Estimate Number I
Contract Limits Payment Number I
Project Type WATER&SEWER For Period Enduig 1/1612018
Project Funding
INTT I:WATER 1MPROVEMENTS
Item Description of Items I MIMAted l)nii Unit Cost &stlmsted Completed Completed
No. Quauity Total Quamty Total
I MOBILIZATION I LS $2,500.00 32,500-00 1 $2,500.00
2 6'WIDE ASPHALT PVi4T REPAIR,ARTERIAL I I LF $225.00 $2,475.00 11 $2,475.00
3 6"CONC CURB AND OU I 1 LR 15 LF $37.00 $555.00 15 $555.00
5 TRENCH SAFETY 72 LF $0.75 $54.00 72 $54.00
6 DUCTILE IRON WATER FITTINGS 0.1 TN $186.00 0.1 $186.00
W/RESTRAlN1
7 6'PVC WATER PIPE 10 LF $55.00 $550.00 10 $550.00
42"WATER SERVICE I EA $2,600.00 $2,600.00 1 $2,600.00
t0 6"GATE VAVLE I EA $900.00 $900.00 1 5900.00
11 121IX8"TAPPING SI,FF.VF&VALVE 1 EA $6,550.00 $6,550.00 I $6.550.00
12 TRAFFIC CONTROL i M0 54,000,00 41,000.00 1 S4,000.00
13 8"DUCTILE[RON PIPE(CO 91) 62 LF $78.00 $4,836.00 62 54,836.00
14 20"CASING BY OTHER THAN OPEN CUT(CO 60 LF $365.00 521,900,00 60 $21,900.00
HI) - - - - - - -- ----
Sub-Total of Previous Unit 547,106.00 $47,106.00
UNIT II:SANITARY SEWER UaROVEMENTS
Item Description of Items Estimated Unit Ihiit Cost Estimated Completed Completed
No. Quanity Total Quanity Total
1 REMOVE CONC PVMT 520 SY $S.SO 31,76000 320 $1,760.00
2 CONCRETE ENCASE SEWER PIPE(CO 4I) 8 CY $175.00 $1,400.00 8 $1,400.00
3 POST-CCTV INSPECTION(CO#1) 991 LF $1.50 $1,486.50 991 $1,486.50
4 MANHOF,LVAC[TIJMTESTING(CO 611) 6 EA $150.00 $900.00 6 $900.00
5 TRENCH SAFETY(CO#1) 1021 LF $1.00 $1,021.00 1021 $1,021.00
6 CONCRETE COLLAR 4 EA $200.00 S800.00 4 $800.00
7 TRENCH WATER STOPS 4 EA $100.00 $400.00 4 $400.00
10 8"SEWER PIPE(CO#1) 996 LF $71.00 $70,716.00 996 $10,716.00
11 8"SEWER PIPE,CSS BACKFILL 25 LF $245.00 $6,125.00 25 $6,125.00
12 4;MANHOLE 4 EA $5,237.50 $20,950.00 4 $20,950.00
13 4'MANHOLE(CIP)(CO N 1) 2 EA .$4,900.00 $9,800.00 2 $9,800.00
14 20'STEEL CASING(CO#1) 10 LF $1110.00 $1,100.00 10 $1,100.00
15 RE1v10VE CONCRETE DOCK(CO MI) 1 EA $3,500.00 $3,500.00 1 $3,500.00
Wednesday,January 24,2018 Page 2 of 5
City Project Numbers 101132 DOE Number 1132
Contract Name S&B TECHNICAL PRODUCTS Estimate Number I
Contract Limits Payment Number I
Project I I ype WATER&SEWER For Period Ending 1/16/7018
Project Funding
16 20*PVC CASING(CO 91) 28 LF $85.00 $2,380.00 28 S2,380.00
17 RFPLACE CONC.DOCK(CO#I) I EA 12,750.00 32.750.00 1 $2,750.00
IS CCTV EXSTiNG MAIN(CO 9 1) 1 LS $1,000.00 $1,000.00 1 $1,000.00
ig RE-MOVE®ROUT NIH PLUG(CO#1) 1 LS $500.00 $500.00 1 $500.00
Sub-Total of Previous Unit $126,588.50 $126,588.50
Wednesday,January 24,2018 Page 3 of 5
City Project Numbers 101132 DOE Number 1132
Contract Name S&B TECHNICAL PRODUCTS Estimate Number I
Contract Limits Payment Number 1
Project Type WATER&SEWER For Period Ending 1/16l2012
Project Funding
Contrnrt Information Summary
Original Contract Amuunt 5146,005.50
Chance Orders
Change Order Number 1 $27,689.00
Total Contract Price S173,694.50
Date Total Cost of Work Completed $173,694.50
Conl<actor Less %Retained SU.00
Net Earned $173,694.50
Date Earned'1'his Period 1173,694.50
Inspection Supervisor
Retainage This Period $0,00
Date Less Liquidated Damages
Project Manager Days 0 /Day $0.00
Date Le.9sPavement Deftcienry 10,00
Asst.DirectorfYPW-lnfrastntcturc Design and(Amstruction Less Penalty .$0.00
Date Less Previous Payment $0.00
Director/Contracting Department Plus Material on Hand Less 15% $0.00
Balance Due This Payment $173,694.50
i
1
Wednesday,January 24,2018 Page 4 of 5
City Project Numbers 101132 DOE Number 1132
Contract Name S&B TECHNICAL PRODUCTS Estimate Number I
Payment Number I
Contract Limits
Project`Type
WATER&SEWER
FarPeriud Ending
Project Funding
Project Manager NA City Secretary Contract Number
lnspectnrs ROLLS 1 MCKINNON Contract Date 10/6!2017
Contractor WALKER UTILITIES,INC. Contract Time 70 CD
P.O.BOX 54122 Days Charged to Date 72 CD
HURST, TX 76054 Contract is .000000 Complete
CITY OF FORT WORTH
SUMMARY OF CHANGES
Cine Fund Account Center Amount Gross Retainage Net
Funded
- - ----------------------- - -
Total Cost of Work Completed $173,694.50
Less %Retained $0.00
Net Earned $173,694.50
Earned This Period $173,694.50
Retainage This Period $0.00
Less Liquidated Damages
0 Days @ $0.00 1 Day $0.00
LessPavement Deficiency $0.00
Less Penalty $0.00
Less Previous Payment $0,00
Pius Material on Hand Less 15% $0.00
Balance Due This Payment $173,694.50
Wednesday,January 24,2018 Page 5 of 5
FORTWORTH
TRANSPORTATION AND PUBLIC WORKS
PIPE REPORT FOR:
PROJECT NAME: S&B Technical Products Lots 1&2 1300 E.Berry St.
PROJECT NUMBER: 101132
DOE NUMBER: N/A
WATER
PIPE LAID SIZE TYPE OF PIPE LF
Domestic 8" Ductile Iron 62
Domestic 6" PVC 10 —
FIRE HYDRANTS: None VALVES(16" OR LARGER)
PIPE ABANDONED SIZE TYPE OF PIPE LF
DENSITIES:
NEW SERVICES: 1-2"domestic
SEWER
PIPE LAID SIZE TYPE OF PIPE LF
Santiary Sewer $" PVC 996
PIPE ABANDONED SIZE TYPE OF PIPE LF
DENSITIES:
NEW SERVICES: 3 PVC
TRANSPORTATION AND PUBLIC WORKS
The Cit} of Fort Forth• 1000 Throckmorton Street• Fort Worth,T-1,776012-6311
(D (817)392-7941 •Fax: (817)392-7845
AFFIDAVIT
STATE OF TEXAS
COUNTY OF TARRANT
Before me, the undersigned authority, a Notary Public in the state and
county aforesaid, on this day personally appeared Brandon Walker,
Vice President, of Walker Utilities Inc., known to me to be a credible
person, who being by me duly sworn, upon his oath deposed and said;
That all persons, firms, associations, corporations or other
organizations furnishing labor and/or materials have been paid in full;
That the wage scale established by the City Council in the City of Fort
worthhas been paid; and
"khat there are no claims pending for personal injury and/or property
darnages;
On Contract described as;
SRB Technical Products Addition Water. Sanitary Sewer, and Driveway
Improvements City Project # 101 132
f
B Y
Subscribed and sworn before me an this rt day of
JASON ESCOBEDO
Notary Public, State of Texa
y; `i` Comm. Expires 02-26 2021-Fo�taryPublic in Tarrant
Notary ID 126817961
,,.� County, Texas
CONSENT OF OWNER o
SURETY COMPANY ARCHITECT ❑
TO FINAL PAYMENT CONIRAC"IOR ❑
AIA DOCUMENT G'07 SURETY Q
OTHER
❑ BOND #4414116
PROJECT: Water,Sanitary Sewer,and Driveway Improvements to Serve S&B Technical Products Addn.Lot 1+2,Block A.
1300 E.Berry,City Project No.101132
(name,address)
TO:(Owner)
CONTRACT FOR:water,Sanitary Sewer,Driveway Improvements
City of Fort Worth, CONTRACT DATE:
101111 Throckmorton Street
Fort Worth,TX 76102
CONTRACTOR:
Walker Utilities,Inc.
In accordance with the provisions of the Contract between the Owner and the t_'ontractur a�, indicated above,the
(here insert name and address of Surety Company)
SureTec insurance Company
1330 Past Oak Blvd.,Suite 1100
Houston,TX 77056 SURETY COMPANY.
on bond of
(here insert name and address of Contractor)
Walker Utilities,Inc.
P.O.Bos 54122 CONTRACTOR,
Hurst,TX 76053
hereby approves of the final payment to the Contractor, and agrees that final payment to the Contractor shall
not relieve the Surety company of any of its obli , ons to
(lu•re in.serr name and address of Owner)
City of Fort Worth OWNER,
1000 Throckmorton Street
Fort Worth,TX 76102
as set forth in the said Surety Company's bond
IN WITNESS WHEROF,
—
The Surety Company has hereunto set its hand this 4th -day of Janu 4 ___
r� ___
SureTec Insurance Company
Surety ompany
Signature of Authorized Representative
` � i
Attorney-in-Fact itnss TenaDonovan
(seal)
Attorney-in-Fact
title
AIA DOCUMENT(:707"CONSE" I'OF SURETY COMPANY TO FINAL PAYMENT=APRIL 1970 EDITION"AIA
1970THEAMERICAN INSTITUTFiOF ARCHI'TECT'S,1735 NEW YORK AVE.NW WASHINGTON,D.C.2006
POA u: 4221800
SureTec Insurance Company
LIMITED POWER OF ATTORNEY
Know All Men by These Presents, That SURETEC INSURANCE COMPANY (the "Company"), a corporation duly organized and
existing under the laws of the State of I'exas, and havui6 its principal office in Houston, Harris County, Texas, does by these presents
make,constitute and appoint
Kathy Sells, Lanny Land, Steven W. Lewis, Trenae Donovan i
its true and lawful Attorney-in-fact, with full power and authority hereby conferred in its name, place and stead,to execute, acknowledge
and deliver any and all bonds, recognizances, undertakings or other instruments'or contracts of suretyship to include waivers to the
conditions of contracts and consents of surety for,providing the bond penalty does not exceed
Five Million and 001100 Dollars($5,000,000.00)
and to bind the Company thereby as fully and to the same extent as if such bond were signed by the President, sealed with the corporate
seal of due Company and duly attested by its Secretary, herebv ratifying and confirming all that the said Attorney-in-Fact may do in the I
premises. Said appointment shall continue in force until 1 213 1 20 1 9 and is made under and by authority of the following
resolutions of the Board of Directors of the SureTec Insurance Company:
Be it Resolved, that the President, any Vice-President, any Assistant Vice-President, any Secretary or any Assistant Secretary shall be and is
hereby vested with full power and authority to appoint any one or more suitable persons as Attorneys)-in-Fact to represent and act for and on
behalf of the Company subject to the following provisions:
4rrorney-In-Face may be given full power and authority for and in the name of and of behalf of the Company, to execute, acknowledge and
deliver,any and all bonds,recognizanec:s,contracts,agreements or indemnity and other conditional or obligatory undertakings and any and all
notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such
Attorney-in-Fact shall Lr bincai i;r upc�r�,the r� mhanv as if sitmed by the Presidrm and sealed and effected by the Corporate Secretary.
5c it Resolved that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or
any certificate relating thereto by facsimile,and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be,valid
and binding upon the Company with respect to any bond or undertaking to which it is attached. (.adopted at a meeting held on 20"of April,
1999.)
I
In IJ'itness Whereof, SURETEC INSURANCE CO vfPANY has caused these presents to be signed by its President, is corporate seal
to be hereto affixed this 13th day of June ,A.D. 2017 • SURETEC SURAN E C . If NA'
S1;>a...,F
By:
f John Knox. ., resid t
w! w ;>
State of Texas ss:
County of Harris
On this ,s.n day of.lune,A.D. 2017 before me personally came John Knox Jr.,to me known,who,being by me y sworn,did depose and say,that he
resides in Houston, Texas, that he is President of SURETEC INSURANCE CONIPAN , the company described in and which executed the above
instrument,that he knows the seal of said Company; that the seal affxcd to said instrument is such corporate seal;that it was so affixed by order of the
Board of Directors of said Company;and that he signed his name thereto by like order.
i
�P;P,�, JACOUEt.YN GREENLEAF
11
°:' H,Notary Public, State of texas
'r= Comm Expires 05-18-2021
so' .••'+: Jacq elyn Greenleaf,Notary Public
'';;�„�•` Notary ID 126903029
hfy commission expires May 18,2021
` I,Ni.Brent Beaty,Assistant Secretary of SURE'1.EU INSUF_A.NCE COMPANY,do hereby certify that the above and foregoing is a true and correct copy
of a Power of Attorney,executed by said Company, which is still in full force and effect;and furthermore, the resolutions of the Board of Directors, set
out in the Power of Attorney are in full force and effect. ((� J I
Given under my hand and the seal of said Company at Houston, Texas this !�T"` day of v� ` A.D.
M.Brent Beaty.Ass.s`art Secretary
Any instrument issued in excess of the penalty stated above is totally void and without any validity.
For verification of the authority of this power you may call(713)812-0800 any business day between 8:00 am and 5:00 pm CST.
DEVELOPER-AWARDED-PROJECT CHANGE ORDER
PROJECT NAME: S&B Technical Products Addition Lots 182,Block A CHANGE
CONTRACT: Water,Sevrer,and Pavi Im rovementsORDER N.:
CFA# 9-1TY PARTICIPATION,
CITY PROJECT 4_101132
DOE{I —NIA
WATER PROJECT# 96008-0600430-101132-001
SEWER PROJECT# 15600"70(A30-101 132-CJOI 360
FILE III K-2543
INSPECTOR' Tommy McKinnon Phone No: 214202-561b
PROJECT MANAGER: Debbie J WIIhPIm Phone No. 817-392-2461
CONTRACT U1411 .,—.'fLiGHTG CONTRACT
---;WATER SEWER PAVING DRAINAGE DAYS
Developer —Developer Developer Developer EiT.Iopir—
Cost City Cost cost — City Cost cost City Cost Cost Cit Cost Costcitycost t —
CR!G!NAL CONTRACT 643,114A0 $0,00 $102,091.60 11040 $67i190+25 50.00 $0.00 f0.00 $0.00 $0.00 60
EXTRAS TO DATE
CREDITS TO DATE
$0.00 $67 IGO 26 $000 $0.00 $0.00 50.00 60
CCNTRACT TO DATE S43,114.00 $0.00 S102,891,60 1- $0.00
$0.00 $0.00 $0.00 $0.00 10
AMGUI IT OF FRCP CHANGE CIRCE, 5 3.09100 $0,00 $ 1369700 $0 Wo S0.00
"00-1-__ 70
$0.00 ',.0i
REVISED CONTRACT AMOUNT $47108.00 --"00 112'1., _ _ $63,869.75 $0.00 1 $0.00 $0.00 $0.00 SOM
TOTAL REVISED CONTRACT AMOUNT
PER UNIT $47,106.00 $128,688.60 $53,E 50.76 50.00— 50.00
REVISED COSTSHARE Dev.Cost: $227,664.26 City Cost; $0.00
TOTAL REVISED CONTRACT $227,664.25
Page I
Revised:10-12-2011
Ynu❑re directed to make the following changes in the contract documents:
_ PAY ITEM it [CfFYBIDITEMI QUANTITY UMT ITEM DESCRIPTION UNIT PRICE TOTAL
UNIT I-WATER
4LF 16"Casingb other than open cut $ 315,00
8 LF 8"Water Pipe $ 62.00 =4 75,S44.ODi
i 3(PIEW ITEM) 82 LF 8"Ductile Iron Pipe $ 75.001$ 4.835.00,
14 NEW ITEM) BD LF 20'Casing by other then open cut r, jao.uu I$21 900.00$,9
SUBTOTAL UNIT I WATER 92.00
UNIT It-SEWER _
j 2 3 CY Concrete Encase Sever Pipe $ 175.00 $ 528,00
3 32 LF Post CCTV Inspection $ 1.50 $ 48.00
4 _ 2 EA Manhole Vacuum Testing $ 150.00 $ 300.00
LF Trench Safety $ 1.00 $ 62.00
8 I EA 6'Sevier Service $ 1,920,00 -i..
9 1 EA 6"2-Way Cleanout $ 750,00
_ 10 62 LF 8"Setwr Pi $ 71.00 $ 4,402.00
11(NEW ITEM) 2 EA 4'Manhole CIP $ 4,900.00 $ 9,800.00
14 NEW ITEM 10 LF 20"Steel Casing $ 110.00 $ 1100.00
hI 15 NEW ITEM 1 LS Remove Concrete Dock $ 3,500.00 $ 3,500.00
F...._
4 18 NEW ITEM 28 LF 20"PVC Casing $ 85.00 $ 2,380.00
li 17(NEW ITEM) 1 LS Replace Concrete Dock $ 2 750.00 $ 2 750.00
18 NEW ITEM 1 LS CCTV ExistingSevier Main $ 1,000.00 $ 1000.00
SIL.. 19(NEW ITEM 1 LS Remove and Ra rout Manhole Plug 5 500.Uu $ 500.00
SUBTOTAL UNIT II-SEWER $ 23,697.00
UNIT III-PAVING
2 -W TN HMAC Transilion $ 340.55
S EA Barrier Free Romp Type P-1 $ 2,200.00
6 EA Barrier Free Ramp Type P-2 $ 21200.00
9 NEW ITEM 25 LF 24"CL III RCP $ 115.00 $$ 2875.00
10 NEW ITEM 1 EA Connect to ExistingGrate Inlet $ 1 800.00
SUBTOTAL UNIT III-PAVING i=.'?;t.5�
TOTAL CHANGE ORDER AMOUNT 24,386.60
REASONS FOR CHANGE ORDER Revised waterline to be duclde iron pipe in 20'steel casing Due togas line conflicts,reel/gment of sanitary sewer was necessary with the addition of pipe
protection. Handicap ramps were not needed of ddvewey and replacement of exisfing 24'stam pipe necessary- Changes correspond to Plan Revision Nos.1
through 3 as shown on sheets C-03,C-04,and C-07 of the construction plans and Field Revision as shown on Sheet C-09.
NO CITY FUNDS INVOLVED IN THIS CONTRACT. DEVELOPER IS RESPONSIBLE FOR 100%OF THE CHANGE ORDER COST AND NO
REIMBURSEMENT FROM THE CITY WILL BE SOUGHT BY THE DEVELOPER.
RECOMMENDED: APPROVED: _ APPROVED:
KiMyrn and Associates,Ino. S&B Techn! Proro7d�uce, rc. l Walker Utllftlea..
�
� r
Name: Hug'Ivlorales,PE George French - '"��•
Title: Troasurer -
Revised:10.12-2011 _ Page 2
U.S. Department of State
STATEMENT OF CONSENT:
ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16
USE OF THIS FORM
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.
FORM INSTRUCTIONS
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.
SPECIAL REQUIREMENTS FOR INSTITUTIONS/ENTITIES GRANTED GUARDIANSHIP
Below is a list of documents you must submit with your DS-3053:
1.A certified 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.
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.
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 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/chIIdabduction or contact the Office of Children's
Issues by telephone at 1-888-407-4747 or by e-mail at PreventAbduction1Dstate.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 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.
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 Legal Affairs and Law Enforcement Liaison,Attn:Forms Officer 44132 Mercure Cir,P.O.Box 1227,Sterling,Virginia 20166-1227.
DS-3053 08-2016 Page 1 of 2