Adjudicated PTA

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD ANALYSIS (PTA)
This form serves as the official determination by the DHS Privacy Office to
identify the privacy compliance requirements for all Departmental uses of
personally identifiable information (PII).
A Privacy Threshold Analysis (PTA) serves as the document used to identify
information technology (IT) systems, information collections/forms, technologies,
rulemakings, programs, information sharing arrangements, or pilot projects that involve
PII and other activities that otherwise impact the privacy of individuals as determined by
the Chief Privacy Officer, pursuant to Section 222 of the Homeland Security Act, and to
assess whether there is a need for additional Privacy Compliance Documentation. A PTA
includes a general description of the IT system, information collection, form, technology,
rulemaking, program, pilot project, information sharing arrangement, or other Department
activity and describes what PII is collected (and from whom) and how that information is
used and managed.
Please complete the attached Privacy Threshold Analysis and submit it to your
component Privacy Office. After review by your component Privacy Officer the PTA is sent
to the Department’s Senior Director for Privacy Compliance for action. If you do not have a
component Privacy Office, please send the PTA to the DHS Privacy Office:
Senior Director, Privacy Compliance
The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
Tel: 202-343-1717
[email protected]

Upon receipt from your component Privacy Office, the DHS Privacy Office will review this
form and assess whether any privacy compliance documentation is required. If compliance
documentation is required – such as Privacy Impact Assessment (PIA), System of Records
Notice (SORN), Privacy Act Statement, or Computer Matching Agreement (CMA) – the DHS
Privacy Office or component Privacy Office will send you a copy of the relevant compliance
template to complete and return.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Privacy Threshold Analysis (PTA)

Specialized Template for
Information Collections (IC) and Forms
The Forms-PTA is a specialized template for Information Collections and Forms. This
specialized PTA must accompany all Information Collections submitted as part of the
Paperwork Reduction Act process (any instrument for collection (form, survey,
questionnaire, etc.) from ten or more members of the public). Components may use this PTA
to assess internal, component-specific forms as well.
Form Number:

I-333

Form Title:

Obligor Change of Address

Component:

Immigration and
Customs Enforcement
(ICE)

Office:

ERO

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Obligor Change of Address
OMB Control
Number:
Collection status:
Name:
Office:

Phone:
Name:

1653-0042
Extension

OMB Expiration
Date:
Date of last PTA (if
applicable):

July 31, 2017
Not applicable

PROJECT OR PROGRAM MANAGER
Justin Gellert
ERO
Title:
Detention and Deportation
Officer
202-732-5462
Email:
[email protected]

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Scott Elmore

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Office:
Phone:

OCIO
Title:
ICE Forms Manager
202-732-2601
Email:
[email protected]
SPECIFIC IC/Forms PTA QUESTIONS

1. Purpose of the Information Collection or Form
a. Describe the purpose of the information collection or form. Please provide a
general description of the project and its purpose, including how it supports the DHS
mission, in a way a non-technical person could understand (you may use
information from the Supporting Statement).
If this is an updated PTA, please specifically describe what changes or upgrades are
triggering the update to this PTA.
This form is submitted by bond obligors who need to inform ICE of a new mailing
address. ICE needs to maintain current obligor address information so that it can
communicate with the obligor, and make payments of interest and principal owed
to the obligor.
As described below in Question 2e, this form includes bond obligor and alien
information such as the name, physical address, and phone number. Obligors can
submit this form in person, and upon presentation, a signed copy will be returned
to the obligor indicating receipt of the address change. Obligors can also submit
the form by mail to the appropriate ERO field office where the bond was posted.

b. List the DHS (or component) authorities to collect, store, and use this information.
If this information will be stored and used by a specific DHS component, list the
component-specific authorities.
The Immigration and Nationality Act, as amended (8 U.S.C. 1103, 1183, 1226,
1229c, and 1363) authorizes the collection of this information to provide for the
posting, maintenance, cancellation, and breach of an immigration surety bond,
and/or associated financial management activities.

2. Describe the IC/Form

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

a. Does this form collect any
Personally Identifiable
Information” (PII 1)?

b. From which type(s) of
individuals does this form
collect information?
(Check all that apply.)

c. Who will complete and
submit this form? (Check
all that apply.)

d. How do individuals
complete the form? Check
all that apply.

☒ Yes
☐ No

☒ Members of the public
☒ U.S. citizens or lawful permanent
residents
☒ Non-U.S. Persons.
☒ DHS Employees
☐ DHS Contractors
☐ Other federal employees or contractors.

☒ The record subject of the form (e.g., the
individual applicant).
☐ Legal Representative (preparer, attorney,
etc.).
☐ Business entity.
If a business entity, is the only
information collected business contact
information?
☐ Yes
☐ No
☐ Law enforcement.
☒ DHS employee or contractor.
☐ Other individual/entity/organization that is
NOT the record subject. Please describe.
Click here to enter text.

☒ Paper.
☐ Electronic. (ex: fillable PDF)
☐ Online web form. (available and submitted via
the internet)
Provide link:

1
Personally identifiable information means any information that permits the identity of an individual to be directly or indirectly inferred, including
any other information which is linked or linkable to that individual regardless of whether the individual is a U.S. citizen, lawful permanent resident,
visitor to the U.S., or employee or contractor to the Department.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

e. What information will DHS collect on the form? List all PII data elements on the
form. If the form will collect information from more than one type of individual,
please break down list of data elements collected by type of individual.
From the bond obligor: Name, physical address, telephone number. The obligor
will also supply the name, physical address, and telephone number of the alien for
whom the bond was posted. Finally, this form collects the Alien File (A-File)
number and bond receipt number.
From DHS Employees: Name, job title, and signature of the official receiving the
form.
f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? Check all that
apply.
☐ Social Security number
☐ DHS Electronic Data Interchange
Personal Identifier (EDIPI)
☒ Alien Number (A-Number)
☐ Social Media Handle/ID
☐ Tax Identification Number
☐ Known Traveler Number
☐ Visa Number
☐ Trusted Traveler Number (Global
☐ Passport Number
Entry, Pre-Check, etc.)
☐ Bank Account, Credit Card, or other
☐ Driver’s License Number
financial account number
☐ Biometrics
☐ Other. Please list:
g. List the specific authority to collect SSN or these other SPII elements.
8 U.S.C. 1103 and 1360 authorize collection of the A-number.

h. How will this information be used? What is the purpose of the collection?
Describe why this collection of SPII is the minimum amount of information
necessary to accomplish the purpose of the program.
ICE collects the A-number (“file number” on the form) to make sure that the form
is placed into the appropriate alien’s file.

i.

Are individuals
provided notice at the
time of collection by

Privacy Threshold Analysis – IC/Form

☒ Yes. Please describe how notice is provided.
The record subject him/herself fills out the form.
☐ No.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

DHS (Does the records
subject have notice of
the collection or is
form filled out by
third party)?

3. How will DHS store the IC/form responses?
a. How will DHS store
☒ Paper. Please describe.
the original,
A copy will be placed into the A-File.
completed IC/forms?
☒ Electronic. Please describe the IT system that will

b. If electronic, how
does DHS input the
responses into the IT
system?

c. How would a user
search the
information
submitted on the
forms, i.e., how is the
information
retrieved?

store the data from the form.
Electronic A-File
☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Scanned forms are maintained both in EARM and the
BMIS SharePoint site.

☒ Manually (data elements manually entered). Please
describe.
If the A-File is digitized, then a copy is sent to the
National Records Center (NRC), who would then
place the form within the digitized file.
☐ Automatically. Please describe.
Click here to enter text.
☒ By a unique identifier. 2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Notice with this PTA.
Information is typically retrieved by either the
name of the obligor or alien.
☐ By a non-personal identifier. Please describe.
Click here to enter text.

2
Generally, a unique identifier is considered any type of “personally identifiable information,” meaning any information that permits the identity
of an individual to be directly or indirectly inferred, including any other information which is linked or linkable to that individual regardless of
whether the individual is a U.S. citizen, lawful permanent resident, visitor to the U.S., or employee or contractor to the Department.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

d. What is the records
Form I-333 falls under Records Retention Schedule
retention
N1-566-08-11, which covers Alien Files. These files
schedule(s)? Include
are kept permanently after transfer to the National
Archives and Records Administration (NARA).
the records schedule
number.
e. How do you ensure
Not applicable. These are permanent records that are
that records are
not destroyed.
disposed of or deleted
in accordance with
the retention
schedule?
f. Is any of this information shared outside of the original program/office? If yes,
describe where (other offices or DHS components or external entities) and why.
What are the authorities of the receiving party?
☐ Yes, information is shared with other DHS components or offices. Please describe.
Click here to enter text.
☐ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
Click here to enter text.
☒ No. Information on this form is not shared outside of the collecting office.

Please include a copy of the referenced form and Privacy Act Statement (if
applicable) with this PTA upon submission.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD REVIEW
(TO BE COMPLETED BY COMPONENT PRIVACY OFFICE)
Component Privacy Office Reviewer:

Date submitted to component Privacy
Office:
Date submitted to DHS Privacy Office:
Have you approved a Privacy Act
Statement for this form? (Only
applicable if you have received a
waiver from the DHS Chief Privacy
Officer to approve component Privacy
Act Statements.)

Jordan Holz
August 3, 2017
Click here to enter a date.

☒ Yes. Please include it with this PTA
submission.
☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
ICE Form I-333 “Obligor Change of Address” is covered under the DHS/ICE/PIA – 005
Bond Management Information System (BMIS) PIA. This PIA states that if obligors
need to correct their address, there is a form that is issued by ERO for that purpose.
This form has SORN coverage under the DHS/ICE 004 – Bond Management
Information System (BMIS).

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD ADJUDICATION
(TO BE COMPLETED BY THE DHS PRIVACY OFFICE)
DHS Privacy Office Reviewer:

Max Binstock

PCTS Workflow Number:
Date approved by DHS Privacy Office:
PTA Expiration Date

1148670
August 22, 2017
August 22, 2020

DESIGNATION

Privacy Sensitive IC or
Form:

Yes If “no” PTA adjudication is complete.

DHS IC/Forms Review:

DHS PRIV has approved this ICR/Form.

Determination:

☐ PTA sufficient at this time.
☐ Privacy compliance documentation determination in
progress.
☐ New information sharing arrangement is required.
☐ DHS Policy for Computer-Readable Extracts Containing SPII
applies.
☒ Privacy Act Statement required.
☒ Privacy Impact Assessment (PIA) required.
☒ System of Records Notice (SORN) required.
☐ Specialized training required.
☐ Other. Click here to enter text.

Date IC/Form Approved August 22, 2017
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
e(3) statement update is required.
Statement:
Please change the Privacy Statement to the Privacy Notice
PTA:
New system PTA required.
BMIS PTA expires 9/18/18
PIA:
System covered by existing PIA
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

If covered by existing PIA, please list: DHS/ICE/PIA-005 Bond
Management Information System (BMIS)
If a PIA update is required, please list: Click here to enter text.
SORN:
System covered by existing SORN
If covered by existing SORN, please list: DHS/ICE-004 Bond
Management Information System (BMIS), February 15, 2011, 76 FR
8761
If a SORN update is required, please list: Click here to enter text.
DHS Privacy Office Comments:
Please describe rationale for privacy compliance determination above.

ICE Privacy is submitting this PTA because Form I-333 Obligor Change of Address is
submitted by bond obligors who need to inform ICE of a new mailing address. ICE
needs to maintain current obligor address information so that it can communicate
with the obligor, and make payments of interest and principal owed to the obligor.
This form includes bond obligor and alien information such as the name, physical
address, and phone number.
PRIV finds that is a privacy sensitive system and a PIA is required because ICE
Privacy collects information from members of the public including United States
Citizens, Lawful Permanent Residents, individuals whose records are covered by the
Judicial Redress Act, and ICE employees. PRIV agrees with ICE Privacy that the BMIS
PIA covers ICE’s need to support the financial management of immigration bonds
posted for the release of aliens in ICE custody.
PRIV finds that a SORN is required because Form I-333 retrieves information by a
unique identifier. PRIV agrees with ICE Privacy that the BMIS SORN provides
coverage. DHS/ICE-004covers the maintenance of records related to the
administration and financial management operations of ICE's immigration bond
program.
PRIV finds that a Privacy Notice is required because Form I-333 collects PII directly
from United States Citizens, Lawful Permanent Residents, or individuals whose
records are covered by the Judicial Redress Act.

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