Authorization for a Child to travel with a non family member

Under penalty of perjury and the laws governing the State of Carolina, I affirm that the following statement is true and correct.

In regards to Christopher Joseph Mayer, a citizen of the United States, born on March 8, 2009 in the city of Hometown, State of New York who carries a United States passport numbered 00000000000, I hereby affirm that I have legal custody of this child and that there are no active nor pending child custody or divorce rulings which involve this child.

I hereby give my full authorization and consent for my child to travel outside the borders of the United States with Joseph Smith who carries a United States passport with the number 00000000000. The purpose of the travel is a vacation.

The trip will begin on March 8, 2009 and will end on March 15, 2009 and will include the following destinations:

MOSCOW
KIEV
ST. PETERSBURG

Parents Signature:
Printed Name:
Date:
Address:

Notary Seal