Evacuee Manifest and Promissory Note

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS-5528 Evacuee Manifest and Promissory Note	Form and Instruction	Modified	Available
Justification for Non-Substantive Change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2016-01-28	Repair queued
Supporting Statement (5-2015 rev).docx	Supporting Statement A	Uploaded 2016-01-28	Available
Legal Authorities (4-2015).docx	Supplementary Document	Uploaded 2015-04-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206882	Evacuee Manifest and Promissory Note	Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0211	ICR Reference No: 201601-1405-004
Status: Historical Inactive	Previous ICR Reference No: 201504-1405-001
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Evacuee Manifest and Promissory Note
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted and continue	Conclusion Date: 01/29/2016
	Date Received in OIRA: 01/28/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2017	36 Months From Approved	05/31/2017
Responses	525	0	525
Time Burden (Hours)	175	0	175
Cost Burden (Dollars)	0	0	0

---

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.

---

Authorizing Statute(s): 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
   US Code: 22 USC 4802 Name of Law: Responsibility of the Secretary of State
  

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:
	80 FR 3716	01/23/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 20060	04/14/2015
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Evacuee Manifest and Promissory Note	DS-5528, DS-5528	Evacuee Manifest and Promissory Note ,   Evacuee Manifest and Promissory Note

---

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: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $23,209

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

---

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: 01/28/2016

---