Form DS-3072 REPATRIATION / EMERGENCY MEDICAL AND DIETARY ASSISTANCE

U.S. Department of State

OMB Approval Number: 1405-0150
Expiration Date: XX-XX-20XX
Estimated Burden: 20 Minutes

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
Issuing

8. Sex
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. If including minor children or incapacitated/incompetent adults, please 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.
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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
Passport No.

60. Sex

61. This Person is My

Male

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

69. Sex

68. Identity Document
Issuing Country
Passport No.

70. This Person is My

Male

OR

Female

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

74. Social Security
Number

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

72. First Name

76. Place of Birth

73. Middle Name

78. Sex

77. Identity Document
Issuing Country
Passport No.

79. This Person is My

Male

OR

Female

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

83. Social Security
Number

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

81. First Name

85. Place of Birth

82. Middle Name

87. Sex

86. Identity Document
Issuing Country
Passport No.

88. This Person is My:

Male

OR

Female

National ID No.
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)

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 will only be eligible for a limited validity U.S. passport.
If my loan is in default, I and all U.S. citizen listed family members will not 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.

3. 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) 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 (Inked, Typed*)

93. Date (mm-dd-yyyy)

* Retyping your name in this box using a digital device is as acceptable as signing with pen and paper.
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Identity Document Number from Line 7

94.

WRITTEN CONSENT TO RELEASE OF INFORMATION UNDER THE PRIVACY ACT

The Privacy written consent is optional and will not affect the Department of State's processing of your loan application.
I voluntarily consent to the Department of State, including U.S. diplomatic and consular missions, providing information about me and persons
listed 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.
95. Signature (Inked, Typed*)

(mm-dd-yyyy)

96. Date

97. I voluntarily consent to the Department of State providing information to the U.S. Department of Health and Human Services (HHS) (Repatriation
Program) and/or its partners and grantees with information to assist in my/our resettlement if needed.
98. Signature (Inked, Typed*)

(mm-dd-yyyy)

99. Date

* Retyping your name in this box using a digital device is as acceptable as signing with pen and paper.
100. If form is signed before Notary Public in the United States for benefit of unaccompanied minor child or incapacitated or incompetent adult abroad.
State of

County of

Personally appeared,

On
Date

, 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 Third Country National/Host Country 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 (Inked, Typed, Digital Signature*)

Name of Post

Name of Consular Officer

Date (mm-dd-yyyy)

Title of Consular Officer

SEAL

* Retyping Consular Officer name in the box using a digital device is acceptable as signing with pen and paper or digitally.
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENT
AUTHORITY: The information on this form is requested under the authority of 22 U.S.C. §§ 2670, 2671, 31 USC 3711 through 31 USC 3720, 22 CFR Part 71 , and E.O.
9397, as amended.
PURPOSE: The principal purpose of the information gathered is to allow U.S. citizens and non-U.S. citizens to apply for repatriation/emergency medical and dietary
assistance in foreign countries, to document when such assistance is approved, and to facilitate debt collection.
ROUTINE USES: The information solicited on this form may be shared with other U.S. or foreign government agencies, consistent with the purposes here described and for
other purposes. More information on the Routine Uses for the system can be found in System of Records Notice, State-05, Overseas Citizens Services Records and the
Prefatory Statement of Routine Uses.
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: CA/OCS/MSU, 10th Floor, SA 17, U.S. Department of State, Washington, DC 20522-1710.

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