To Whom It May Concern:

l"vte, Ktrt-yu uqt f. r<tvtrLA ANP _--

amlarc the lau.ful custodial parent and/or non-custoclial parent(s) or legal guardian(s) of:

Chiid's full name:

Date of Birth:
Flace of Birth:
U.S. Passport N-o-u*r.
Date and Place of Issuance of U.S. Passport

_ has my/our consent to travel with:

F=il narne cf accomranying person:

U.S. or foreignpassport number:
Date and Place of issuance of tiris passpos;

to visit durine the period of _

iNamc of Foreign Country) @
Sarin.e that period. will be residing with

at the following address:

(Name of Person Who Chrld wllt be Resrdrng Wfth rn -lorergn Uounb),i

Number/street address and apartment number:

City, State/Province, Country:
?btrephone anC fax numbers (rvork. cell phone and residence)

Signature: nua-l,r.- Date: $fttt oq, aot /

Ful1Fiarc*: klKtrNr/t/t f.tkv{L4
signature:-
- Date:

Illr.l.l
Ulr l\i-*a'
l\arlrL.

Signed before *", ,

ql

re
thr.
(Name of Luarron)

-
Signature: