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 Child under Age 16	Form and Instruction	New	Repair queued
Form DS-5525 Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Child under Age 16	Form and Instruction	New	Repair queued
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	Removed	Available
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	Removed	Repair queued
DS-5525_Expires 113023_OMB No. 1405 0216_30-Day FRN_Legal Authorities.docx	Supplementary Document	Uploaded 2023-12-08	Repair queued
Justification for Nonsubstantive ICR.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-01-28	Repair queued
DS-5525_30day_2019_Legal Authorities_FINAL.docx	Supplementary Document	Uploaded 2019-08-27	Repair queued
DS-5525_Expires 113023_OMB No. 1405 0216_30-Day FRN_ PRA Supporting Statement.docx	Supporting Statement A	Uploaded 2023-12-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
263838	Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Child under Age 16	Form and Instruction	New	Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Child under Age 16
263838	Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Child under Age 16	Form and Instruction	New
207427	Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor Under Age 16	Form and Instruction	Removed	STATEMENT OF EXIGENT/SPECIAL FAMILY CIRCUMSTANCES FOR ISSUANCE OF A U.S. PASSPORT TO A MINOR UNDER AGE 16
207427	Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Minor Under Age 16	Form and Instruction	Removed

ICR Details

OMB Control No: 1405-0216	ICR Reference No: 202312-1405-001
Status: Active	Previous ICR Reference No: 202101-1405-011
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: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/19/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/08/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2028	36 Months From Approved
Responses	28,933	0	0
Time Burden (Hours)	14,467	0	0
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: 18 USC 1621 Name of Law: Perjury Generally
   US Code: 22 USC 211a Name of Law: Authority to Grant, Issue, and Verify Passports
   US Code: 22 USC 212-214 Name of Law: Persons Entitled to Passport
   EO: EO 11295 Name/Subject of EO: Rules Governing the Granting, Issuing, and verifying of United States Passports
   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: 8 USC 1001 Name of Law: Statements or Entries Generally
  

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:
	88 FR 12181	10/02/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 12282	12/08/2023
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 Child under Age 16	DS-5525	Statement of Exigent/Special Family Circumstances for Issuance of a U.S. Passport to a Child under Age 16
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	28,933	0	0	28,933	-12,484	12,484
Annual Time Burden (Hours)	14,467	0	0	14,467	-6,242	6,242
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: Changing Regulations

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

Burden Reduction Due to:

Short Statement: The projected average number of DS-11 respondents from FY 2023-25 is 12,055,600. Through a Department-led frequency analysis, it was determined that 0.24% of DS-11s had a DS-5525 attached to it. Therefore, the projected number of respondents to the DS-5525 over the next 3 years is 28,933.

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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

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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: 12/08/2023

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