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

Forms and Documents

Document Name	Status
Form DS-3053 Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16 Form	Modified
Legal Authorities - DS-3053 (1-2011).docx Supplementary Document	2011-02-08
DS-3053 Supporting Statement (1-2011).docx Supporting Statement A	2011-02-08

IC Document Collections

IC ID	Document Title	Status
14999	Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16 Form	Modified

ICR Details

OMB Control No: 1405-0129	ICR Reference No: 201102-1405-003
Status: Historical Active	Previous ICR Reference No: 200710-1405-005
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/23/2011
	Date Received in OIRA: 02/08/2011
Terms of Clearance: This form will expire on December 31, 2013 at the request of the Department of State.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2013	12/31/2013	02/28/2011
Responses	1,025,000	0	605,800
Time Burden (Hours)	1,025,000	0	605,800
Cost Burden (Dollars)	2,562,500	0	1,042,000

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Abstract: This form is used when both parents or legal guardians of a minor child under age 16 cannot be present at the time the minor's passport application is executed.

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Authorizing Statute(s): PL: Pub.L. 106 - 113 Section 1000 (a)(7)), Name of Law: Foreign Relations Authorization Act, Fiscal Year 2000 and 2001
   US Code: 22 USC 211a Name of Law: Authority to grant, issue, and verify passports
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1400-AC28	Final or interim final rulemaking	72 FR 44	03/07/2007

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 118	06/21/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 197	10/13/2010
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16	DS-3053, DS-3053, DS-3053, DS-3053	Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 14 ,   Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16 ,   Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16 ,   Statement of Consent or Special Circumstances: Issuance of a Passport to a Minor Under Age 16

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,025,000	605,800	0	0	419,200	0
Annual Time Burden (Hours)	1,025,000	605,800	0	0	419,200	0
Annual Cost Burden (Dollars)	2,562,500	1,042,000	0	0	1,520,500	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Change indicated is due to increase in number of respondents

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Annual Cost to Federal Government: $45,660

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/08/2011

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