Form Language

WRITTEN CONSENT TO RELEASE OF INFORMATION UNDER THE PRIVACY ACT.”

Instead it should be called “94. WRITTEN CONSENT TO RELEASE OF PERSONAL INFORMATION

UNDER THE PRIVACY ACT”

The Privacy Act authorization written consent is optional and will not affect the Department of State's processing of your loan application.

I authorize voluntarily consent to the Department of State, including U.S. diplomatic and consular missions, to release 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.)  [box] family [box] friends [box]  individual members of congress, [box] member s of the press, and [box] the general public.

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENT

AUTHORITY: The information on this form is requested under the authority of 22 U.S.C. § 2671, 2715, 4802, and 2357, 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 document the travel of and loan issuance to eligible persons who use U.S. government coordinated transport out of a crisis location and to facilitate debt collection [DELETE provide an accurate list of U.S. citizens and non-U.S. citizens being

evacuated from foreign countries in times of crisis. The information will also assist in collection of expenses incurred by the U.S.

Government for evacuations.]

ROUTINE USES: The information on this form may be shared with other U.S. or foreign government agencies, and other relevant individuals and entities, consistent with the purposes here described and for other purposes. More information on the Routine Uses for the system can be found in the System of Records Notice State-05, Overseas Citizens Services Records and Other Overseas Records and the Department of State's Prefatory Statement of Routine Uses.

DISCLOSURE: Furnishing the requested information is voluntary. Failure to provide the information requested on this form 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, 600 19^th Street, N.W., SA-17, U.S. Department of State, Washington, D.C. 20520-1710.

SBU - LEGAL