Affidavit Regarding A Change of Name

OMB Control No: 1405-0133	ICR Reference No: 201709-1405-005
Status: Historical Active	Previous ICR Reference No: 201407-1405-005
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Affidavit Regarding A Change of Name
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: 10/30/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/29/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2020	36 Months From Approved	10/31/2017
Responses	161,239	0	183,037
Time Burden (Hours)	107,493	0	122,025
Cost Burden (Dollars)	272,494	0	2,152,515

---

Abstract: The Affidavit Regarding a Change of Name (DS-60) 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 that a passport applicant has adopted a new name without formal court proceedings or a marriage and has publicly and exclusively use the adopted name over a long period of time (generally five years). The affidavit must be executed by an affiant who has personal knowledge of the facts of the applicant's use of both their birth name and their newly adopted name in question.

---

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:
	82 FR 18807	04/21/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 45656	09/29/2017
Did the Agency receive public comments on this ICR? No

---

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

IC Title Form No. Form Name Affidavit Regarding A Change of Name DS-60 Affidavit Regarding a Change of Name

---

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	161,239	183,037	0	-21,798	0	0
Annual Time Burden (Hours)	107,493	122,025	0	-14,532	0	0
Annual Cost Burden (Dollars)	272,494	2,152,515	0	-1,880,021	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: The hour burden adjustments indicated reflects a slight increase in the number of projected affiants from 159,671 (previous FYs 2015-2017) to 161,239 (FYs 2017-2019). Projections are based on information request letters sent to applicants that require the use of the DS-60. The yearly projected numbers of affiants 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-60 is expected to increase and decrease in correlation with the DS-11 application estimate through FY 2019.

---

Annual Cost to Federal Government: $2,419

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? Uncollected

Agency Contact: Alexys Garcia 202 736-9216 [email protected]

---

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: 09/29/2017

---