Eligibility Questionnaire For HAVANA Act Payments

Eligibility Questionnaire for HAVANA Act Payments

Documents and Forms

Document Name Document Type
Form DS-4316 Eligibility Questionnaire For HAVANA Act Payments Form and Instruction
DS-4316 Eligibility Questionnaire for HAVANA Act Payments 06. DS4316 - DRAFT - 12-22-2025.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Eligibility Questionnaire For HAVANA Act Payments	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 22 CFR 135

Information Collection 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	06. DS4316 - DRAFT - 12-22-2025.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: STATE-31 Human Resources Records	FR Citation: 78 FR 43258

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	30	-70	100
Annual IC Time Burden (Hours)	15	-35	50
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.