Form DS-3072 Repatriation/Emergency Medical and Dietary Assistance Lo

OMB APPROVAL NO. 1405-0150
EXPIRATION DATE: XX/XX/20XX
ESTIMATED BURDEN: 20 MINUTES

U.S. Department of State

REPATRIATION / EMERGENCY MEDICAL AND DIETARY ASSISTANCE LOAN APPLICATION
PART 1 - APPLICATION TO BE COMPLETED BY EACH ADULT APPLICANT REGARDLESS OF NATIONALITY
1. Last Name (Print Clearly)

4. Social Security Number

2. First Name

5. Date of Birth
(mm-dd-yyyy)

3. Middle Name

6. Place of Birth

7. Identity Document

8. Sex

Issuing Country

Male

Passport No.
Female

OR

National ID No.
9. Current lodging where you may be contacted now .
10. Phone number where you may be contacted now.

11. E-mail address where you may be contacted now.

12. Medical condition, current injuries, or limited mobility relevant to evacuation.

13. Verifiable Billing Address at Final Destination in United States or other Permanent Address (Not a Post Office Box)
14. Address Line 1
15. Address Line 2
16. City

18. Country

17. State/Province

19. Postal Code

20. Telephone Number(Include Country/City Codes)

21. E-mail Address

22. Emergency Contact (Do not list someone traveling with you)
24. First Name

23. Last Name (Print Clearly)
25. Address Line 1
26. Address Line 2
27. City

28. State/Province

29. Country

31. Telephone Number (Include Country/City Codes)

30. Postal Code

32. E-mail Address

33. Relationship to you

34. Minor Children or Incapacitated/Incompetent Adults to be Repatriated or to Receive Emergency Medical and Dietary Assistance, list below.
Check here if none
35. Last Name (Print Clearly)

38. Social Security
Number

39. Date of Birth
(mm-dd-yyyy)

36. First Name

40. Place of Birth

37. Middle Name

41. Identity Document
Issuing Country

42. Sex
Male

Passport No.
OR

Female

National ID No.
44. Last Name (Print Clearly)

47. Social Security
Number

48. Date of Birth
(mm-dd-yyyy)

45. First Name

49. Place of Birth

43. This Person is My

46. Middle Name

50. Identity Document
Issuing Country

51. Sex

52. This Person is My

Male

Passport No.
OR

Female

National ID No.
DS-3072
07-2020

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Identity Document Number from Line 7
53. Last Name (Print Clearly)

56. Social Security
Number

57. Date of Birth
(mm-dd-yyyy)

54. First Name

58. Place of Birth

55. Middle Name

59. Identity Document
Issuing Country

60. Sex
Male

Passport No.
OR

Female

National ID No.
62. Last Name (Print Clearly)

65. Social Security
Number

66. Date of Birth
(mm-dd-yyyy)

63. First Name

67. Place of Birth

64. Middle Name

68. Identity Document
Issuing Country
Passport No.

69. Sex

Female

National ID No.

74. Social Security
Number

75. Date of Birth
(mm-dd-yyyy)

72. First Name

76. Place of Birth

73. Middle Name

77. Identity Document

78. Sex

Issuing Country
Passport No.
OR

83. Social Security
Number

84. Date of Birth
(mm-dd-yyyy)

81. First Name

85. Place of Birth

79. This Person is My

Male
Female

National ID No.
80. Last Name (Print Clearly)

70. This Person is My

Male

OR

71. Last Name (Print Clearly)

61. This Person is My

82. Middle Name

86. Identity Document
Issuing Country
Passport No.
OR

National ID No.

87. Sex

88. This Person is My:

Male
Female

89. PART 2 - Promissory Note and Repayment Agreement
1.

I promise to repay the U.S. Government in U.S. dollars or the foreign currency equivalent, within 30 days of initial billing, and if not repaid within 60 days of initial billing at
an interest rate established in accordance with Federal law, for Emergency, Medical and Dietary Assistance or Repatriation loans. This loan is in addition to any other
U.S. Government loans received for other purposes. I will keep the Department of State's Accounts Receivable Branch informed of my address(es) until I repay my loan in
full. If I am unable to pay this loan in full, the Department of State may, at its discretion and upon my request, forward to me an installment agreement containing an
installment plan for repayment of my loan.

2.

I understand that:
(a)
(b)
(c)
(d)
(e)

3.

My obligation to repay my loan will not be considered paid in full until it clears through the account of the Treasurer of the United States.
Until I have paid my loan in full, I and all listed U.S. citizen family members may be refused a U.S. passport.
If my loan is in default, I and all U.S. citizen listed family members will only be eligible for limited validity U.S. passports.
My loan will be subject to interest, penalties, and other charges for late payment as directed by law and regulation.
I will be liable to pay any costs for collection.

I will include my name, date of birth, place of birth, and Social Security number with all correspondence, payments, and questions. I will make payment to the
Department of State, Accounts Receivable by credit/debit card, check or money order payable to Accounts Receivable Branch, PO Box 979005, St. Louis, MO
63197-9000. Send questions by mail or courier (DHL, FedEx, UPS, etc.) to: Accounts Receivable Branch, Comptroller and Global Financial Services, Department of
State, 2010 Bainbridge Ave., North Charleston, SC 29405. To make inquiries by telephone: From the U.S. or Canada, call: 1-800-521-2116 or internationally, call
843-746-0592.
To make inquires by email, contact: [email protected]).

4. I understand that assistance requested from the Department of Health and Human Services (HHS), if any, will be provided based on availability upon arrival in the United
States. In addition, reception and resettlement assistance provided by HHS is in the form of a loan which has to be paid back to the U.S. Government.

90. Signature Block for Applicant
I hereby accept the foregoing terms and conditions of repayment for myself and persons listed.
91. Full Name Printed
92. Signature
DS-3072

93. Date (mm-dd-yyyy)
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Identity Document Number from Line 7

94.

CONSENT TO RELEASE OF INFORMATION UNDER THE PRIVACY ACT

Providing this consent is optional and will not affect the Department of State's processing of your loan application.
I consent to the Department of State, including U.S. diplomatic and consular missions, releasing information about me and persons listed on this form
related to our current EMDA and/or repatriation case and this loan application to:
(Please place a check in the following boxes for the people to whom you authorize information to be released.)
family,
friends,
individual
members of congress,
members of the press,
and the general public. I also acknowledge the Privacy Act Statement on the next page of this form.

(mm-dd-yyyy)

96. Date

95. Signature

97. If form is signed before a Notary Public in the United States for benefit of unaccompanied minor child or incapacitated or incompetent adult abroad.
State of

County of

On
Date

Personally appeared,

, before me
(mm-dd-yyyy)

(Notary)

Notary Public for My Commission Expires
(Signer)

PART 3 - CONSULAR NOTES - For Official Use Only
No Signature of Loan Recipient - Minor

No Social Security Number

No Signature of Loan Recipient - Incapacitated/Incompetent Adult

Escort (No Familial Relationship)

Loan Includes Temporary Subsistence

Other (Please Explain)

If applicable, list U.S. citizen associated with Foreign National, accompanying spouse or partner, or escort of primary applicant.
Name of the U.S. Citizen

Date of Birth

Place of Birth

Social Security Number

Repatriation to United States or Emergency Medical or Dietary Assistance Abroad (EMDA) Loan Amount
Amount in Foreign Currency

Amount in U.S. Currency

The above total includes U.S. Dollars currency for subsistence for the followng dates:
currency for Repatriation/Emergency Medical and Dietary Assistance.

and U.S. Dollars
From (mm-dd-yyyy)

To (mm-dd-yyyy)

PART 4 - CONSULAR OFFICER SIGNATURE AND CERTIFICATION
The undersigned consular officer approves the loan specified above.

Signature of Consular Officer

Name of Post

Typed or Printed Name of Consular Officer

Date (mm-dd-yyyy)

SEAL
Title of Consular Officer
PRIVACY ACT STATEMENT
AUTHORITY: The information on this form is requested under the authority of 22 U.S.C. §§ 2670, 2671; 31 U.S.C. § 7701, and E.O. 9397, as amended
by E.O. 13478.
PURPOSE: The principal purpose of the information gathered is to ensure the Department of State has accurate data regarding U.S. citizens and any
non-U.S. citizens receiving repatriation/emergency medical and dietary assistance in foreign countries, and to obtain and record their promise to repay
a loan that is extended. The applicant’s Social Security number is collected for identity and loan repayment purposes.
ROUTINE USES: The information solicited on this form may be made available to the U.S. Department of Health and Human Services (HHS)
(Repatriation Program) and/or its partners and grantees to assist in the applicant(s)’ resettlement if needed. This information may also be made
available to other government agencies to assist the U.S. Department of State in processing repatriation/emergency medical and dietary assistance
documentation and related services, law enforcement, and administrative purposes. More information on the routine uses the Department of State
relies on can be found in System of Records Notice, State-05, Overseas Citizens Services Records, State-26, Passport Records, and the Prefatory
Statement of Routine Uses published in the Federal Register.
DISCLOSURE: Furnishing the requested information is voluntary, but failure to provide it may result in delays in reviewing the application or in an
inability to provide the requested assistance.
PAPERWORK REDUCTION ACT (PRA) STATEMENT
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time required for searching existing
data sources, gathering the necessary documentation, providing the information and/or documents required, 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:
U.S. Department of State, CA/OCS/L, SA-17, 10th Floor, Washington, DC 20522-1707.
DS-3072

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