Public Charge Questionnaire

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0234 can be found here:

Documents and Forms

Document Name Document Type
Form DS-5540 Public Charge Questionnaire Form and Instruction
DS-5540 PUBLIC CHARGE QUESTIONNAIRE DS-5540.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Public Charge Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection 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 %

	Approved	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

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.