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 2019-06-26	Available
DS-5528 .docx	Justification for No Material/Nonsubstantive Change	Uploaded 2018-07-11	Available
FINAL - Supporting Statement - DS 5528.docx	Supporting Statement A	Uploaded 2017-05-12	Available
Final Legal Authorities DS-5528.docx	Supplementary Document	Uploaded 2017-05-05	Repair queued

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: 201906-1405-003
Status: Active	Previous ICR Reference No: 201807-1405-003
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Evacuee Manifest and Promissory Note
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/09/2019
	Date Received in OIRA: 06/26/2019
Terms of Clearance: Agency will continue to abide by any previous terms of clearance.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2020	07/31/2020	07/31/2020
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 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
   US Code: 22 USC 2671 Name of Law: Emergency Expenditures
  

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:
	82 FR 6685	01/19/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 21294	05/05/2017
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, DS-5528	Evacuee Manifest and Promissory Note ,   Evacuee Manifest and Promissory Note ,   EVACUEE MANIFEST AND PROMISSORY NOTE

---

ICR Summary of Burden

table that charts list 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	525	525	0	0	0	0
Annual Time Burden (Hours)	175	175	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: $26,508

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 06/26/2019

---