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pdfU.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.
DS-3072
04-2024
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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.
DS-3072
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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.
DS-3072
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File Type | application/pdf |
File Title | DS-3072 |
Subject | Emergency Loan Application and Evacuation Documentation (Formerly OF-28) |
File Modified | 2024-06-13 |
File Created | 2024-06-13 |