Information Collection

Signature Card

IC 214064 under ICR 202104-1405-003 · OMB 1405-0105.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0105 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-4139 SIGNATURE CARD	Form
Form DS-4139 SIGNATURE CARD SIGNATURE CARD	Form
DS-4139 SIGNATURE CARD DS-4139.pdf	Form
DS-4139 SIGNATURE CARD DS-4139.pdf	Form

IC Title:

SIGNATURE CARD

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	DS-4139				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: 4,139

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,139	4,139
Annual IC Time Burden (Hours)	345	345
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.

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