Form DS-7781 Adoptive Family Relief Act Refund Application

U.S. Department of State

ADOPTIVE FAMILY RELIEF ACT REFUND APPLICATION

OMB APPROVAL NO. 1405-0223
EXPIRES: 12-31-2019
ESTIMATED BURDEN: 5 MIN.

PERSONAL INFORMATION
Petitioner's Name (Last, First, Middle)
Visa Applicant's Name (Last, First, Middle)
Petitioner Email

Petitioner Phone Number

Case Number

Fee Amount Paid

Date(s) of Visa Reissuance(s), if known
Refund Check Recipient (Last, First)
Refund Address (Street, City, State)

Please send the form to the Consular Section where your adoption case was processed.
For a full list of United States Consular Sections refer to http://www.usembassy.gov/
PRIVACY ACT STATEMENT
AUTHORITY: Collection of this information is authorized by 8 U.S. Code § 1201, Public Law 114-70, The Adoptive Family Relief Act and by
regulations issued pursuant to 22 CFR part 42.
PURPOSE: The information solicited on this form will be used to determine your eligibility to receive an immigrant visa refund.
ROUTINE USES: The information on this form may be shared with federal, state, and local government agencies, members of Congress, and officials
of foreign governments in accordance with certain approved routine uses. More information on the Routine Uses for the system can be found in
System of Records Notice, State-39, Visa Records.
DISCLOSURE: Responding to this form is voluntary. Failure to provide the information requested on this form may result in the applicant's inability to
receive benefits.
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time required for searching existing
data sources, gathering the necessary documentation, providing the information, and reviewing the final collection. You do not have to supply
this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate
and/or recommendations for reducing it, please send them to: [email protected]
DS-7781
04-2016