Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor Under Age 16

Forms and Documents

Document Name	Status
Form DS-5525 Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor Under Age 16 Form and Instruction	New
Legal Authorities - DS-5525 (6-2013).docx Supplementary Document	2013-06-20
DS-5525 Supporting Statemebnt (6-2013).docx Supporting Statement A	2013-06-20

IC Document Collections

IC ID	Document Title	Status
207427	Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor Under Age 16 Form and Instruction	New

ICR Details

OMB Control No: 1405-0216	ICR Reference No: 201306-1405-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor Under Age 16
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/15/2013
	Date Received in OIRA: 06/20/2013
Terms of Clearance: OMB requests that DOS pursue development of an electronic means of submitting the form in compliance with GPEA.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2016	36 Months From Approved
Responses	115,050	0	0
Time Burden (Hours)	57,525	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Information collected on the DS-5525, "Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor Under Age 16", is used in conjunction with the DS-11, "Application for a U.S. Passport". The DS-5525 can serve as the statement describing exigent or special family circumstances, which is required if written consent of the non-applying parent or guardian cannot be obtained when the passport application is executed for a minor under age 16.

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Authorizing Statute(s): US Code: 8 USC 1104 Name of Law: Powers and duties of Secretary of State
   US Code: 18 USC 1542-1544 Name of Law: False statement in application and use of passport
   US Code: 26 USC 6039E Name of Law: Information concerning resident status
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 74725	12/17/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 37269	06/20/2013
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 Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor Under Age 16	DS-5525	Statement of Exigent/Special Family Circumstances for Issuance of a U.S. 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	115,050	0	0	115,050	0	0
Annual Time Burden (Hours)	57,525	0	0	57,525	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: Bueden changes due to submission as a new collection.

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Annual Cost to Federal Government: $8,392

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: 06/20/2013

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