Public Charge Questionnaire

Forms and Documents

Document Name	Status
Form DS-5540 Public Charge Questionnaire Form and Instruction	Modified
DS-5540 30 Day - Legal Authorities.docx Supplementary Document	2020-06-03
DS-5540 30 Day - Supporting Statement.docx Supporting Statement A	2020-06-03

IC Document Collections

IC ID	Document Title	Status
240038	Public Charge Questionnaire Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0234	ICR Reference No: 202006-1405-001
Status: Historical Inactive	Previous ICR Reference No: 202002-1405-002
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Public Charge Questionnaire
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 08/06/2020
	Date Received in OIRA: 06/03/2020
Terms of Clearance: Because of the preliminary injunction that was issued against the Department in the Southern District of New York (Make the Road New York, et al. v. Pompeo et al.), the Department of State wishes to withdraw the certifications under 5 CFR part 1320 for this information collection, which were submitted on June 3, 2020 and February 2, 2020.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved	08/31/2020
Responses	0	0	397,814
Time Burden (Hours)	0	0	1,790,163
Cost Burden (Dollars)	0	0	0

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Abstract: The Department seeks to better ensure that aliens subject to the public charge inadmissibility ground are self sufficient and will not rely on public resources to meet their needs, but rather, will rely on their own capabilities, as well as the resources of sponsors. Through the DS–5540, the Department will collect information in a standardized format regarding applicants’ ability to financially support themselves following entry into the United States, without depending on government assistance. Fields primarily pertain to the applicant’s health, family status, assets, resources, financial status, education, skills, health insurance coverage, and tax history. The DS–5540 would also require applicants to provide information on whether they have received certain specified public benefits from a U.S. Federal, state, local or tribal government entity.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 57142	10/24/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 33772	06/02/2020
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Public Charge Questionnaire	DS-5540	PUBLIC CHARGE QUESTIONNAIRE

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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:

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Annual Cost to Federal Government: $5,000,000

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.     No

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? No

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Common Form ICR:  No

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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: 06/03/2020

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