Information Collection

Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16

IC 14999 under ICR 201010-1405-005 · OMB 1405-0129.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0129 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-3053 Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16	Form
DS-3053 Statement of Consent or Special Circumstances: Issuance Internet DS-3053 Form.pdf www.travel.state.gov	Form
DS-3053 Statement of Consent or Special Circumstances: Issuance DS-3053 10-23-2007.pdf www.travel.state.gov	Form and Instruction
DS-3053 Statement of Consent or Special Circumstances: Issuance OMB Passback DS-3053 12-4-07.pdf www.travel.state.gov	Form and Instruction
DS-3053 Statement of Consent or Special Circumstances: Issuance DS-3053 (10-2010).pdf www.travel.state.gov	Form and Instruction
Justification for change to DS-3053.doc Justification for change to DS-3053	IC Document

IC Title:

Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 22 CFR 51.27

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DS-3053	Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 14	Internet DS-3053 Form.pdf	www.travel.state.gov	No		Fillable Printable
Form and Instruction	DS-3053	Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16	DS-3053 10-23-2007.pdf	www.travel.state.gov	Yes	No	Fillable Printable
Form and Instruction	DS-3053	Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16	OMB Passback DS-3053 12-4-07.pdf	www.travel.state.gov	Yes	No	Fillable Printable
Form and Instruction	DS-3053	Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16	DS-3053 (10-2010).pdf	www.travel.state.gov	Yes	No	Fillable Printable

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,025,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,025,000	419,200	605,800
Annual IC Time Burden (Hours)	1,025,000	419,200	605,800
Annual IC Cost Burden (Dollars)	2,562,500	1,520,500	1,042,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification for change to DS-3053	Justification for change to DS-3053.doc	10/26/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.