Birth Affidavit

Forms and Documents

Document Name	Status
Form DS-10 Birth Affidavit Form	New
Form D-10 Birth Affidavit Form and Instruction	Removed
DS-10_Expires 103123_OMB No. 1405-0132_30-Day FRN_Legal Authorities.docx Supplementary Document	2023-10-26
DS-10 Legal Authorities.docx Supplementary Document	2020-06-08
DS-10_Expires 103123_OMB No. 1405-0132_30-Day FRN_PRA Supporting Statement.docx Supporting Statement A	2023-10-26

IC Document Collections

IC ID	Document Title	Status
263048	Birth Affidavit Form	New
15005	Birth Affidavit Form and Instruction	Removed

ICR Details

OMB Control No: 1405-0132	ICR Reference No: 202310-1405-003
Status: Received in OIRA	Previous ICR Reference No: 202006-1405-002
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	Date Submitted to OIRA: 10/26/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2023
Responses	6,028	5,183
Time Burden (Hours)	4,018	3,455
Cost Burden (Dollars)	0	29,750

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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.

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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

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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 12117	08/14/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 12245	10/26/2023
Did the Agency receive public comments on this ICR? No

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

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

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ICR Summary of Burden

	Total Request	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	6,028	5,183	0	6,028	-5,183	0
Annual Time Burden (Hours)	4,018	3,455	0	4,018	-3,455	0
Annual Cost Burden (Dollars)	0	29,750	112,544	-112,544	-29,750	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 respondents for Form DS-11 from FY 2023-2025 is 12,055,600. Through a Department-led time and motion study, it was determined that Form DS-10 was attached to 0.05 percent of Form DS-11 receipts. Therefore, the projected number of annual respondents for Form DS-10 is 6,028.

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Annual Cost to Federal Government: $5,731

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: 10/26/2023

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