Birth Affidavit

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form D-10 Birth Affidavit	Form and Instruction	Modified	Available
DS-10 LegalAuthorities.docx	Supplementary Document	Uploaded 2017-06-27	Available
FINAL - 1405-0132 (DS-10).docx	Supporting Statement A	Uploaded 2017-06-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
15005	Birth Affidavit	Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0132	ICR Reference No: 201706-1405-003
Status: Historical Active	Previous ICR Reference No: 201406-1405-003
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Birth Affidavit
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: 07/31/2017
	Date Received in OIRA: 06/27/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2020	36 Months From Approved	07/31/2017
Responses	22,056	0	21,585
Time Burden (Hours)	14,711	0	14,390
Cost Burden (Dollars)	32,422	0	247,580

---

Abstract: The Birth Affidavit (DS-10) form is submitted in conjunction with an application for a U.S. passport. It is used by Passport Services to collect information for the purpose of establishing the birth in the Unted States of a passport applicant who has not submitted an acceptable United States birth certificate with his or her passport application. An affiant who has personal knowledge of the fats of the applicant's birth in the United States must use the DS-10 in order to execute the affidavit.

---

Authorizing Statute(s): US Code: 22 USC 211a Name of Law: Authority to grant, issue, and verify passports
   EO: EO 11295 Name/Subject of EO: Rules governing the granting, issuing, and verifying of United States passports
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 89181	12/09/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 28928	06/26/2017
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Birth Affidavit	D-10	Birth Affidavit

---

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	22,056	21,585	0	471	0	0
Annual Time Burden (Hours)	14,711	14,390	0	321	0	0
Annual Cost Burden (Dollars)	32,422	247,580	0	-215,158	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: 15. The hour burden adjustments indicated reflect an increase in the number of projected respondents from 21,585 (previous FYs 2015 – 2017) to 22,056 (FYs 2017-2019). Projections are based on information request letters sent to applicants that require the use of the DS-10. This method provides higher numbers than actual forms used since every applicant may not respond to the information request. The yearly projected numbers of respondents are based on demand forecast numbers from statistical models and historical trends of form usage. The primary driver for form usage is the demand forecast for each fiscal year. The next two fiscal years’ forecasts are updated on an annual basis so that each forecast uses the most recent, relevant date to project future demand. Given that projected passport application (DS-11) demand is the primary driver for form usage, as shown below in the table, the DS-10 is expected to increase and decrease steadily in correlation with the DS-11 application estimate through FY 2019.

---

Annual Cost to Federal Government: $330

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

---

Common Form ICR:  No

---

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: 06/27/2017

---