Form DS-3072 Repatriation/Emergency Medical and Dietary Assistance Lo

OMB APPROVAL NO. 1405-0150
EXPIRATION DATE:
ESTIMATED BURDEN: 20 MINUTES

U.S. Department of State

REPATRIATION/EMERGENCY MEDICAL AND DIETARY ASSISTANCE LOAN APPLICATION
PART 1 - APPLICATION TO BE COMPLETED BY EACH ADULT APPLICANT REGARDLESS OF NATIONALITY
1. Last Name (Print Clearly)

4. Social Security Number

2. First Name

3. Middle Name

5. Date of Birth
6. Place of Birth
(DD-MMM-YYYY)

7. Identity Document

8. Sex

Issuing Country

Male

Passport No.
OR

Female

National ID No.

9. Current lodging where you may be contacted now
10. Phone number where you may be contacted now

11. Email address where you may be contacted now

12. Medical condition, current injuries, or limited mobility relevant to evacuation

13. Verifiable Billing Address at Final Destination in United States or other Permanent Address (Not a Post Office Box)
14. Address Line 1
15. Address Line 2
16. City

18. Country

17. State/Province

19. Postal Code

20. Telephone Number (Include Country/City Codes)

21. Email Address

22. Emergency Contact (Do not list someone traveling with you)
24. First Name

23. Last Name (Print Clearly)
25. Address Line 1
26. Address Line 2
27. City

28. State/Province

29. Country

31. Telephone Number (Include Country/City Codes)

30. Postal Code

32. Email Address

33. Relationship to you

34. Minor Children or Incapacitated/Incompetent Adults to be Repatriated or to Receive Emergency Medical and Dietary Assistance, list below.
Check here if none
35. Last Name (Print Clearly)

38. Social Security
Number

39. Date of Birth
(DD-MMM-YYYY)

36. First Name

40. Place of Birth

37. Middle Name

41. Identity Document

42. Sex

Issuing Country

43. This Person is My:

Male

Passport No.
OR

44. Last Name (Print Clearly)

47. Social Security
Number

48. Date of Birth
(DD-MMM-YYYY)

45. First Name

49. Place of Birth

Female

National ID No.
46. Middle Name

50. Identity Document
Issuing Country

51. Sex

52. This Person is My:

Male

Passport No.
OR

DS-3072

National ID No.

Female
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Identity Document Number from Line 7
53. Last Name (Print Clearly)

56. Social Security
Number

57. Date of Birth
(DD-MMM-YYYY)

54. First Name

58. Place of Birth

55. Middle Name

59. Identity Document

60. Sex

Issuing Country

61. This Person is My:

Male

Passport No.
OR

62. Last Name (Print Clearly)

65. Social Security
Number

66. Date of Birth
(DD-MMM-YYYY)

63. First Name

67. Place of Birth

Female

National ID No.
64. Middle Name

68. Identity Document

69. Sex

Issuing Country

70. This Person is My:

Male

Passport No.
OR

71. Last Name (Print Clearly)

74. Social Security
Number

75. Date of Birth
(DD-MMM-YYYY)

72. First Name

76. Place of Birth

Female

National ID No.
73. Middle Name

77. Identity Document

78. Sex

Issuing Country

79. This Person is My:

Male

Passport No.
OR

80. Last Name (Print Clearly)

83. Social Security
Number

84. Date of Birth
(DD-MMM-YYYY)

81. First Name

85. Place of Birth

Female

National ID No.
82. Middle Name

86. Identity Document
Issuing Country

87. Sex

88. This Person is My:

Male

Passport No.
OR

National ID No.

Female

89. PART 2 - Promissory Note and Repayment Agreement
1.

I promise to repay the U.S. Government in U.S. dollars or the foreign currency equivalent, within 30 days of initial billing, and if not repaid within 60 days of initial billing at
an interest rate established in accordance with Federal law, for Emergency, Medical and Dietary Assistance or Repatriation loans. This loan is in addition to any other
U.S. Government loans received for other purposes. I will keep the Department of State's Accounts Receivable Branch informed of my address(es) until I repay my loan in
full. If I am unable to pay this loan in full, the Department of State may, at its discretion and upon my request, forward to me an installment agreement containing an
installment plan for repayment of my loan.

2.

I understand that:
(a)
(b)
(c)
(d)
(e)

My obligation to repay my loan will not be considered paid in full until it clears through the account of the Treasurer of the United States.
Until I have paid my loan in full, I and all listed U.S. citizen family members will only be eligible for a limited validity U.S. passport.
If my loan is in default, I and all U.S. citizen listed family members will not be eligible for limited validity U.S. passports.
My loan will be subject to interest, penalties, and other charges for late payment as directed by law and regulation.
I will be liable to pay any costs for collection.

3.

I will include my name, date of birth, place of birth, and Social Security number with all correspondence, payments, and questions. I will make payment to the
Department of State, Accounts Receivable by credit/debit card, check or money order payable to Accounts Receivable Branch, PO Box 979005, St. Louis, MO
63197-9000. (Send questions by mail to: Accounts Receivable Branch, Global Financial Services, Department of State, PO Box 150008, Charleston, SC 29415-5008.
Send questions by courier (DHL, Fedex, UPS, etc.) to: Accounts Receivable Branch, Global Financial Services 1969 Dyess Ave., Building 646-B, North Charleston, SC
29405. To make inquiries by telephone: From the U.S. or Canada, call: 1-800-521-2116 or internationally, call 843-746-0592. To make inquiries by email, contact:
[email protected].)

4.

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.

90. Signature Block for Applicant
I hereby accept the foregoing terms and conditions of repayment for myself and persons listed.
91. Full Name Printed
92. Signature

93. Date (DD-MMM-YYYY)
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Identity Document Number from Line 7

94.

AUTHORIZATION FOR RELEASE OF INFORMATION UNDER THE PRIVACY ACT

The Privacy Act authorization is optional and will not affect the Department of State's processing of your loan application.
I authorize the Department of State, including U.S. diplomatic and consular missions, to release information about me and persons listed to:
(Please place a check in the following boxes for the people to whom you authorize information to be released.)
family,
friends,
members of congress,
members of the press,
and the general public.

individual

96. Date (DD-MMM-YYYY)

95. Signature

97. I authorize the Department of State to provide information to the U.S. Department of Health and Human Services (HHS) (Repatriation Program)
and/or its partners and grantees with information to assist in my/our resettlement if needed.
99. Date (DD-MMM-YYYY)

98. Signature

100. If form is signed before Notary Public in the United States for benefit of unaccompanied minor child or inconpacitated or incompetent adult abroad.
State of

, before me
On
Date (DD-MMM-YYYY)

County of

Personally appeared,

(Notary)

Notary Public for My Commission Expires
(Signer)

PART 3 - CONSULAR NOTES - For Official Use Only
No Signature of Loan Recipient - Minor

No Social Security Number

No Signature of Loan Recipient - Incapacitated/Incompetent Adult

Escort (No Familial Relationship)

Loan Includes Temporary Subsistence

Other (Please Explain)

If applicable, list U.S. citizen associated with Third Country National/Host Country National, accompanying spouse or partner, or escort of
primary applicant.
Name of the U.S. Citizen

Date of Birth

Place of Birth

Social Security Number

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 U.S. Dollars currency for subsistence for the followng dates:
currency for Repatriation/Emergency Medical and Dietary Assistance.

and U.S. Dollars
From (mm-dd-yyyy)

To (mm-dd-yyyy)

PART 4 - CONSULAR OFFICER SIGNATURE AND CERTIFICATION
The undersigned consular officer approves the loan specified above and certifies the persons listed boarded the transport.

Name of Post

Signature of Consular Officer

Typed or Printed Name of Consular Officer

Date (DD-MMM-YYYY)

SEAL
Title of Consular Officer
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 and E.O. 9397, as amended.
PURPOSE: The principal purpose of the information gathered is to provide an accurate list of U.S. citizens and non-U.S. citizens receiving
repatriation/emergency medical and dietary assistance in foreign countries.
ROUTINE USES: The information solicited on this form may be made available to other government agencies to assist the U.S. Department
of State in processing repatriation/emergency medical and dietary assistance documentation and related services, law enforcement and
administrative purposes. More information on the Routine Uses for the system can be found in System of Records Notice, State-05,
Overseas Citizens Services Records and the Prefatory Statement of Routine Uses published in the Federal Register.
DISCLOSURE: Furnishing the requested information is voluntary, but failure to provide it may result in delays in reviewing the application or
in an inability to provide the requested assistance.
PAPERWORK REDUCTION ACT (PRA) STATEMENT
Public reporting burden for this collection of information is estimated to average 20 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: CA/OCS/L, 4th Floor, SA-29,
U.S. Department of State, Washington, DC 20522-2202.
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