Information Collection

Evacuee Manifest and Promissory Note

IC 206882 under ICR 201601-1405-004 · OMB 1405-0211.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0211 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-5528 Evacuee Manifest and Promissory Note	Form and Instruction
DS-5528 Evacuee Manifest and Promissory Note DS-5528 (4-2015).pdf	Form and Instruction
DS-5528 Evacuee Manifest and Promissory Note ds5528_proposed1_2016.pdf	Form and Instruction
Justification for Non-Substantive Change.docx Justification for Non-substantive change	IC Document

IC Title:

Evacuee Manifest and Promissory Note

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 22 CFR Part 71 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-5528	Evacuee Manifest and Promissory Note	DS-5528 (4-2015).pdf		Yes	No	Fillable Printable
Form and Instruction	DS-5528	Evacuee Manifest and Promissory Note	ds5528_proposed1_2016.pdf		Yes	No	Fillable Printable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records

Title: Overseas Citizens Services Records - State 05

FR Citation: 73 FR 24342

Number of Respondents: 525

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	525	525
Annual IC Time Burden (Hours)	175	175
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification for Non-substantive change	Justification for Non-Substantive Change.docx	01/28/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.