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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
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	Modified	Available
Legal Authorities - DS-5525.docx	Supplementary Document	Uploaded 2016-07-08	Available
DIR Review - DS-5525 2016 30-daysupstmntex FINAL.docx	Supporting Statement A	Uploaded 2016-07-08	Available

IC Document Collections

Information collection document groups

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

ICR Details

OMB Control No: 1405-0216	ICR Reference No: 201607-1405-004
Status: Historical Active	Previous ICR Reference No: 201306-1405-004
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/30/2016
	Date Received in OIRA: 07/08/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved	08/31/2016
Responses	43,526	0	115,050
Time Burden (Hours)	21,763	0	57,525
Cost Burden (Dollars)	0	0	0

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Abstract: The Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor under Age 16 (DS-5525) is used in conjunction with the Application for a U.S. Passport (DS-11). This form is only for use if the written consent of the non-applying parent or guardian cannot be obtained. The statement must explain in detail the non-applying parent or guardian's unavailability, and recent efforts made to contact the non-applying parent/guardian. This form is not to be used if the non-applying parent/guardian refuses, or claims it is inconvenient, to provide notarized consent for the minor applicant.

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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:
	81 FR 17753	03/30/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 43696	07/05/2016
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

table that charts list 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	43,526	115,050	0	-71,524	0	0
Annual Time Burden (Hours)	21,763	57,525	0	-35,762	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	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: Yes

Burden Reduction Due to: Changing Forms

Short Statement: Demand forecast projections, by their nature, will have some uncertainty in their accuracy, which can explain differences between actual and forecast. However, the decrease from the previous estimates (115,050 respondents to 43,526) may be attributed to the short time this form has been in existence. The DS-5525, Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor under Age 16, was introduced in the last three year cycle and the Department is still adjusting its impact on forecasts and workload.

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Annual Cost to Federal Government: $42,890

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: 07/08/2016

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