DS-3072 Emergency Loan Application and Evacuation Documentation

OMB APPROVAL NO. 1405-0150
EXPIRATION DATE:
ESTIMATED BURDEN: 10 MINUTES

U.S. Department of State

EMERGENCY LOAN APPLICATION AND EVACUATION DOCUMENTATION
Personal Principal Adult Family Member Information or Unaccompanied U.S. Citizen Minor
1. Name (Last, First, Middle)
4. Date of Birth (mm-dd-yyyy)

2. Social Security Number

3. Nationality
6. Sex

5. Place of Birth

Male

Female

7. Accompanying Family Members (Immediate family: spouse, children, etc. not household staff) Other eligible persons must apply individually.
Date (mm-dd-yyyy)
Nationality
Minor
Medical
Name
Sex
Relationship to Principal
and Place of Birth
(Yes/No) (Specify)
(Specify)

8. Verifiable Address at Final Destination in United States or other Home of Record
(Not a Post Office Box)
Street Address

City

ZIP/Postal Code

Country

Telephone Number (Include Country Code, City Code, Phone Number)

9. Identify Whose Address is Listed in Item 8
Applicant's Permanent Address
Parent's Residence (Insert Name of Owner/Resident)
Sibling's Residence (Insert Name of Owner/Resident)
Friend's Residence (Insert Name of Friend)
Hospital (Insert Name)
Other (Insert Name of Owner/Resident)

PART 1 - EMERGENCY LOAN APPLICATION: Applicants should complete pages 1, 2 and 3
I HEREBY APPLY FOR A U.S. GOVERNMENT ASSISTANCE LOAN (Check all that are applicable)
Evacuation: (International Crisis)

10.

Emergency Medical
and Dietary Assistance

Repatriation

U.S. Citizen Prisoner

Medical Repatriation of U.S. Citizen (and/or
accompanying immediate family members)

Escort Required

11. Promissory Note: (Check Appropriate Box(es))
I am a citizen of the United States and I hereby promise to repay to the United States Government within 90 days after the signing of this (or upon
release, if imprisoned), and at an interest rate established in accordance with Federal Law, all applicable expenses (including, but not limited to,
transportation, subsistence, medical attention) incurred by the U.S. Government incident to my evacuation/repatriation/emergency medical and dietary
assistance. (Box should be checked by U.S. Citizens applying for crisis evacuation, emergency medical and dietary assistance or repatriation loans.)
I further understand that as the principal adult U.S. citizen applicant(s) for repatriation or emergency medical and dietary assistance my U.S. passport
will be canceled and I will be issued a passport limited for direct return to the U.S. (upon release, if imprisoned). As the principal adult U.S. citizen
applicant(s), my name will be included in the passport lookout system until the debt has been repaid. (Box should be checked by U.S. citizen adults
applying for repatriation or emergency medical and dietary assistance loans.)
I am a citizen of (Country - not U.S.)
, and I understand that my government and the U.S. will determine
the amount and means of repayment. I also understand that my government may seek reimbursement from me for funds expended.
(Box should be checked by all non U.S. citizens applying for crisis evacuation loan/assistance.)
I clearly understand that I am accepting evacuation/repatriation of my own free will and at my own risk. In a crisis evacuation, the cost of transportation
charged to me will be based on the most recent full coach fare to the flight destination. I further understand that the evacuation flight may not comply
with normal international and safety regulations, and in the case of military aircraft travel, the U.S. Government acts only as agent and not as
contracting carrier. (Box should be checked by all U.S.citizens and non-U.S. citizens applying for crisis evacuation loan/assistance.)
I understand that assistance requested from the Department of Health and Human Services (HHS) will be provided based on availability upon arrival in
the United States. In addition, reception and resettlement assistance provided by HHS is in the form of a loan which has to be paid back to the U.S.
Government. (Box should be checked by all persons requiring HHS reception and resettlement assistance in the United States.)
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Last Name

First Name

Social Security Number

Middle Name

TO BE COMPLETED BY U.S. CONSULAR OFFICER
12. Repatriation to United States or Emergency Medical or Dietary Assistance Abroad (EMDA) Loan Amount
Amount in Foreign Currency
Amount in U. S. Currency
The Above Total Includes DOL (U.S. Dollars) for Subsistence

Date From (mm-dd-yyyy)

Date To (mm-dd-yyyy)

And DOL (U.S. Dollars) For Repatriation/Emergency Medical and Dietary Assistance

TO BE COMPLETED BY U.S. CONSULAR OFFICER
13. Evacuation from Crisis to Safe Haven Loan Amount (Equivalent to most recent full coach fare to flight destination.)
Amount in U. S. Currency
Amount in Foreign Currency

Evacuation From

on Date (mm-dd-yyyy)

to

14. Loan Repayment Agreement: TO BE COMPLETED BY LOAN APPLICANTS
1. I understand that:
(a) my obligation to repay the funds provided will not be discharged until payment in full has cleared through the account of the Treasurer of the United
States;
(b) the loan will be subject to the interest, penalties, and other such charges for late payment as directed by law and regulation;
(c) I will not be eligible for a full validity U.S. passport for travel abroad if the loan is in default until the funds provided have been repaid in full; and
(d) I may not be eligible for a full validity U.S. passport for travel abroad if the loan has not been paid in full.
2. I promise to repay (Insert Amount)
representing the U.S. dollar equivalent of the funds advanced within 90 days after the signing of this
note (or upon release, if imprisoned), and to keep the Department of State, Bureau of Resource Management, Accounts Receivable, informed of my
address(es), until such time as the funds are repaid in full.
3. I agree that if I fail to make full payment within 90 days, the Department of State may declare this promissory note in default, and turn the account over
to the U.S. Department of Treasury, the Department of Justice or a private collection agency.
4. I further understand that in the event I am unable to pay this loan in full within 90 days, Bureau of Resource Management, Accounts Receivable of the
Department of State, may, at its discretion and upon my request, determine and forward to me a new promissory note containing an installment plan for
repayment of the loan.
5. I understand that I will be liable to pay any costs for collection.
6. I will make payment by check or money order payable to the Department of State, Accounts Receivable and mail to Accounts Receivable Division, PO
Box 979005, St. Louis, MO 63197-9000.
7. Inquiries should be sent to: Accounts Receivable Division, Global Financial Services, PO Box 150008, Charleston, SC 29415-5008.
Inquiries via DHL, FEDEX, UPS, etc., should be sent to: Accounts Receivable Division, Global Financial Services 1969 Dyess Ave., Building 646-B,
Charleston, SC 29405 Telephone Number 1-800-521-2116.
15. Signature Block for Applicant(s)
The undersigned hereby accepts responsibility for repayment of the funds provided under the conditions outlined in the foregoing. For joint applications by
spouses each party is individually responsible for the loan.
Full Typed or Printed Name

Signature

Full Typed or Printed Name of Spouse
Spouse's signature (if a joint application, both must sign.)
Date (if a joint application, both must sign.)
16. If Applying Jointly
Spouse's Date of Birth (mm-dd-yyyy)

Spouse's Social Security Number

Spouse's Place of Birth (City, State/Province, Country)

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Last Name

First Name

Social Security Number

Middle Name

17. Verifiable Addresses of Applicant (s)
Complete Address Abroad

Complete Address in the United States of America

18. Emergency Contacts (Name, Address, Phone Number, Fax, E-Mail, Relationship)

19.

AUTHORIZATIONS FOR RELEASE OF INFORMATION UNDER THE PRIVACY ACT

(Your decision whether or not to sign these authorizations is optional and will not affect the Department of State’s processing of your
application for assistance.)
1.

I do hereby authorize the U.S. Department of State, as well as U.S. Diplomatic and Consular Missions, to release information concerning my
welfare and emergency evacuation/repatriation/emergency medical and dietary assistance to family, friends, individual members of Congress,
members of the press, and the general public (Strike Out Inapplicable Items) .
Signature(s)

2.

Date (mm-dd-yyyy)

By signing here you authorize the Department of State to provide HHS (Repatriation Program) and/or its partners and grantees information
regarding your medical and other pertinent personal information. Information received by HHS and/or its partners and grantees will be used in
accordance with the U.S. HIPAA (Health Insurance Portability and Accountability Act) law. This statute protects the privacy of individuals receiving
health services in the United States by limiting the ways providers can use patients' personal medical information. HIPAA also protects medical
records and other individually identifiable health information, whether it is on paper, in computers or communicated orally.
Signature(s)

Date (mm-dd-yyyy)

EVACUATION DOCUMENTATION
For Official Use Only: Not to be completed by the applicant

PART 2
Check
Block(s)

Total
Number
Documented U.S. Citizen(s) (Check Evidence Presented) :
U.S. Passport
Naturalization Certificate
U.S. Birth Certificate
Certificate of Citizenship
Consular Report of Birth Abroad of a U.S. Citizen
Probable U.S. Citizen(s). (Consular officer satisfied as to U.S. citizenship claim, but post unable to issue
passport due to crisis.) (The case should be reviewed and name cleared before passport issued or
admitted to U.S. Explain: Cite Evidence Examined or Basis for Conclusion)

Lawful/Probable U.S. Permanent Resident. Evidence for Conclusion
Host Country National with a U. S. Visa (Type)
Third Country National (List Country of Nationality) with a U.S. Visa (Type)
Orphan Approved for Visa. Issuance Not Possible Due to Crisis
Other (Example: Refugee, Humanitarian Parole, etc.) (Specify)
Immediate Relative Alien (non-parent) accompanying a U.S. citizen Minor (with a U.S. Visa) (Type) OR
(Eligible for a U.S. Visa) (No U.S. Visa) (Only one escort permitted per child).
Medical Need (Specify)
U.S. Citizen Minor(s), Alien Minor(s) and escort (with a U.S. Visa) (Type) or eligible for a U.S. visa)
Group Affiliation
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Last Name

First Name

Social Security Number

Middle Name

PART 3 - CONSULAR CERTIFICATION - For Official Use
Consular officer should use this space to explain:
lack of signature by beneficiary of loan;
lack of signature by other person who may take responsibility for loan on behalf of citizens adjudged to be mentally incompetent by a court of
competent jurisdiction;
lack of signature by unaccompanied minors under 18;
lack of Social Security Number(s);
lack of verifiable U.S. address;
Consular officers should insert dollar/foreign currency amounts of loans in items 12, 13 and 14/2.

20. Consular Adjudication Notes: (e.g., Minor Child Found Alone Abroad, No Next-of-Kin Located; U.S. Citizen Found Mentally Incompetent
by Court; Medical Patient Gravely Ill, Insufficient Time to Apply for and Obtain Social Security Number from SSA) ; Impossible to Obtain
Signature of Loan Recipient (Why)) .

21.

CONSULAR OFFICER SIGNATURE AND CERTIFICATION

The undersigned consular officer approves the loan specified above.

Signature of Consular Officer

Name of Post

Typed or Printed Name of Consular Officer

Date (mm-dd-yyyy)

Title of Consular Officer

SEAL

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PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENT
AUTHORITY: The information on this form is requested under the authority of 22 U.S.C. §
2670, 2671, 2715 and 4802, 24 U.S.C. § 322, 42 U.S.C. § 1313, 22 C.F.R. Part 71 including §§
71.1, 71.6, 71.7 and 45 C.F.R. Parts 211 and 212. The Secretary of State is required by law at
22 U.S.C. § 2671(d)(1) to request both a verifiable address and Social Security number at the
time of loan application. Although furnishing the information, including Social Security
number, is voluntary, applicants may not be eligible for the requested assistance if they do
not provide the required information.
PURPOSE: The principal purpose of the information gathered is to provide an accurate list of
U.S. citizens and non-U.S. citizens being evacuated from foreign countries in times of crisis.
The information will also assist in collection of expenses incurred by the U.S. Government for
evacuation, repatriation of citizens to the U.S. (destitute or medical emergency cases), and
ROUTINE USES: The information solicited on this form may be made available as a routine
use to other government agencies to assist the U.S. Department of State in processing
emergency loan and evacuation documentation, and requests for related services, and for law
enforcement and administrative purposes, such as debt collection by the U.S. Government. It
may also be disclosed pursuant to court order. Information may be made available to other
U.S. agencies and their contractors, and to commercial air carriers to assist in aviation
security and resettlement of the family/individual and to foreign emergency medical personnel
if critical medical care is needed. The information may be made available to foreign
government agencies to fulfill passport control and immigration duties, to investigate or
prosecute violations of law, or when a request for information is made pursuant to customary
international practice. The information may also be made available to private U.S. citizen
"wardens" designated by U.S. embassies and consulates to assist in emergency and
evacuation situations and to the Red Cross. For further information on routine uses, please
visit http://foia.state.gov/issuances/priviss.asp.
PAPERWORK REDUCTION ACT (PRA) STATEMENT
Public reporting burden for this collection of information is estimated to average 10 minutes
per response, including time required for searching existing data sources, gathering the
necessary documentation, providing the information and/or documents required, and
reviewing the final collection. You do not have to supply this information unless this
collection displays a currently valid OMB control number. If you have comments on the
accuracy of this burden estimate and/or recommendations for reducing it, please send them
to: A/GIS/DIR, Room 2400, SA-22, U.S. Department of State, Washington, DC 20522-2202.

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