Evacuee Manifest and Promissory Note

Forms and Documents

Document Name	Status
Form DS-5528 Evacuee Manifest and Promissory Note Form and Instruction	New
DS-5528 Legal Authorities (5-2013).doc Supplementary Document	2013-05-13
DS-5528 Supporting Statement (5-2013).doc Supporting Statement A	2013-05-13

IC Document Collections

IC ID	Document Title	Status
206882	Evacuee Manifest and Promissory Note Form and Instruction	New

ICR Details

OMB Control No: 1405-0211	ICR Reference No: 201305-1405-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Evacuee Manifest and Promissory Note
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/27/2013
	Date Received in OIRA: 05/14/2013
Terms of Clearance: Approved for two years only due to lack of GPEA compliance. This form cannot be submitted online.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved
Responses	790	0	0
Time Burden (Hours)	263	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The DS 5528, Evacuee Manifest and Promissory Note, is used to document the evacuation of persons from abroad when their lives are endangered by war, civil unrest, or natural disaster; document issuance of a crisis evacuation loan; to obtain a Privacy Act waiver to share information about the welfare of a citizen or lawful permanent resident with designated persons; and to facilitate debt collection.

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Authorizing Statute(s): US Code: 22 USC 4802 Name of Law: Responsibility of the Secretary of State
   US Code: 22 USC 2671 Name of Law: Emergency Expenditures
   US Code: 22 USC 2715 Name of Law: Procedures regarding major disasters and incidents abroad affecting United States Citizens
  

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:
	78 FR 13140	02/26/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 27469	05/10/2013
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
Evacuee Manifest and Promissory Note	DS-5528	Evacuee Manifest and Promissory Note

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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	790	0	0	790	0	0
Annual Time Burden (Hours)	263	0	0	263	0	0
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: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: Burden changes noted are the result of this submission as a new collection.

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Annual Cost to Federal Government: $2,816,867

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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

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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: 05/14/2013

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