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	Modified
DS-5525_30day_2019_Legal Authorities_FINAL.docx Supplementary Document	2019-08-27
DS-5525_30day_2019_SuppStmt_FINAL.docx Supporting Statement A	2019-08-27

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	Modified

ICR Details

OMB Control No: 1405-0216	ICR Reference No: 201908-1405-004
Status: Active	Previous ICR Reference No: 201607-1405-004
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: 11/13/2020
	Date Received in OIRA: 08/27/2019
Terms of Clearance: The agency will ensure this form is fillable within one year.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2023	36 Months From Approved	11/30/2020
Responses	12,484	0	43,526
Time Burden (Hours)	6,242	0	21,763
Cost Burden (Dollars)	0	0	0

---

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.

---

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

---

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:
	84 FR 27181	06/11/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 44961	08/27/2019
Did the Agency receive public comments on this ICR? Yes

---

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

---

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	12,484	43,526	0	-31,042	0	0
Annual Time Burden (Hours)	6,242	21,763	0	-15,521	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: Miscellaneous Actions

Short Statement: Demand forecast projections, by their nature, will have some uncertainty in their accuracy, which can explain differences between actual and forecast. The decrease from the previous estimates (43,526 respondents to 37,451) is attributed to the decrease in projected DS-11s over the next three years (from 11,763,831 for FY 2016-2018 to 11,015,000 from FY 2019 to 2021).

---

Annual Cost to Federal Government: $6,193

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

---

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: 08/27/2019

---