Information Collection

Public Charge Questionnaire

IC 239988 under ICR 202002-1405-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-5540 Public Charge Questionnaire	Form and Instruction
DS-5540 Public Charge Questionnaire DS-5540.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-5540	Public Charge Questionnaire	DS-5540.pdf		Yes	Yes	Fillable Fileable

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 397,814

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	397,814	397,814
Annual IC Time Burden (Hours)	1,790,163	1,790,163
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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