Information Collection

Eligibility Questionnaire For HAVANA Act Payments

IC 253057 under ICR 202204-1405-006 · OMB 1405-0250.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0250 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-4316 Eligibility Questionnaire For HAVANA Act Payments	Form and Instruction
DS-4316 Eligibility Questionnaire for HAVANA Act Payments ds4316.pdf eforms.state.gov	Form and Instruction
DS-4316 Eligibility Questionnaire for HAVANA Act Payments DS-4316 Final 6-21-2022.pdf eforms.state.gov	Form and Instruction

IC Title:

Eligibility Questionnaire For HAVANA Act Payments

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 22 CFR 135

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-4316	Eligibility Questionnaire for HAVANA Act Payments	DS-4316 Final 6-21-2022.pdf	eforms.state.gov	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	50	50
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.