ICE Form XXX

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DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement
FLIGHT MANIFEST INFORMATION AND AGREEMENT TO REIMBURSE
Privacy Notice
Authorities: U.S. Immigration and Customs Enforcement (ICE) is authorized to collect your information under the
following legal authorities: 5 U.S.C. § 301 (Departmental Regulations), and Federal Aviation Administration statute, 49
U.S.C. § 44909 (Passenger Manifest), as implemented by Department of Homeland Security (DHS) Management
Directive 0020.1, Aviation Management and Safety (Feb. 20, 2005). The collection of your Social Security Number (SSN)/
Individual Taxpayer Identification Number (ITIN) is authorized by the Internal Revenue Code (26 U.S.C. 6109).
Purposes: ICE is collecting your information, including your SSN/ITIN for two reasons: First, ICE will verify your identity
before you board an ICE-chartered aircraft to assess the safety of the aircraft, its crew, other passengers, and the United
States. Further, your data collected on the form is also used in the event of an emergency to help ensure timely
notification of points of contact designated by the passenger. Second, information will be used to confirm your agreement
to be billed for Space Available travel, and for billing and collection purposes.
Agency Disclosure of Information: For United States Citizens, Lawful Permanent Residents, or individuals whose records
are covered by the Judicial Redress Act of 2015 (5 U.S.C. § 552a note), your information may be disclosed in accordance
with the Privacy Act of 1974, 5 U.S.C. § 552a(b), including pursuant to the routine uses published in the DHS/ALL-008 Accounts Receivable System of Records, which can be viewed at https://www.dhs.gov/system-records-notices-sorns.
For all others, as appropriate under United States law and DHS policy, the information you provide may be shared
internally within the U.S. Department of Homeland Security (DHS), and airport personnel who require it to perform their
official duties. ICE may share your information with Department of State personnel and with other Federal and State law
enforcement agencies, and Federal judicial and administrative courts and tribunals, consistent with Federal law and
policy. Your information may also be shared with the Department of the Treasury.
Effects of Collection and Disclosure: Providing your information, including your SSN/ITIN is voluntary. However, if you
decide not to provide this information, you will not be allowed to board the ICE-chartered aircraft.

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Generally, an aircraft used exclusively for the U.S. government may be considered a "public aircraft" as defined in 49
U.S.C. §§ 40102 and 40125, unless it is transporting passengers or operating for commercial purposes. A public aircraft is
not subject to many Federal aviation regulations, including requirements related to aircraft certification, maintenance, and
pilot certification. If a U.S. government agency transports passengers on a Government aircraft, that agency must comply
with all Federal aviation regulations applicable to civil aircraft. If you have questions about the status of a particular flight,
you should contact the agency sponsoring the flight. You and your dependents have certain rights and benefits in the
unlikely event that you are injured or killed while riding abroad a Government aircraft. Federal employees and some
private citizens are eligible for workers' compensation benefits under the Federal Employees' Compensation Act (FECA).
When FECA applies, it is the sole remedy. For more information about FECA and its coverage, consult with your agency's
benefits office or contact the Branch of Technical Assistance at the Department of Labor's Office of Workers'
Compensation Programs. State or foreign laws may provide for product liability or "third party" causes of action for
personal injury or wrongful death. If you have questions about a particular case or you believe you have a claim, you
should consult with an attorney.
Some insurance policies may exclude coverage for injuries or death sustained while traveling aboard a Governmentchartered aircraft while within a combat area. You may wish to check your policy or consult with your insurance provider
before your flight. The insurance available to Federal employees through the Federal Employees Group Life Insurance
Program does not contain an exclusion of this type. If you are the victim of an air disaster resulting from criminal activity
Victim and Witness Specialists from the Federal Bureau of Investigation and/or local U.S. Attorney's Office will keep you
or your family informed about the status of the criminal investigation(s) and provide information about rights and services,
such as crisis intervention, counseling, and emotional support. State crime victim compensation may be able to cover
crime-related expenses, such as medical costs, mental health counseling, funeral and burial costs, and lost wages or loss
of support. The Office for Victims of Crimes in the Department of Justice is authorized by the Antiterrorism Act of 1996 to
provide emergency financial assistance to state programs, as well as the relevant U.S. Attorney's Office, for the benefit of
victims of terrorist acts or mass violence.
If you are a Federal employee, and you are injured or killed on the job during the performance of duty, including travel on
a Government-chartered aircraft, you and your family are eligible to collect workers' compensation benefits under FECA.
Although you may have a cause of action against potentially liable third parties, you and your family may not file a
personal injury or wrongful death suit against the United States or its employees. Further, a choice must normally be
made between FECA disability or death benefits, and those payable under your retirement system. You may choose the
benefit that is more favorable to you.
If you are a private citizen not employed by the Federal government, but you are rendering personal service to the Federal
government on a voluntary basis or for nominal pay, you may be defined as a Federal employee for purposes of FECA. If
so, you and your family would be eligible to receive workers' compensation benefits under FECA, but you may not collect
in a personal injury or wrongful death lawsuit against the United States or its employees. You and your family could still
file suit against potentially liable third parties. Before you depart on a Government-chartered flight, you may wish to
consult with the agency sponsoring the flight to clarify whether you are considered a Federal employee. If you are not
determined to be a Federal employee, you and your family are not eligible to receive workers' compensation benefits
under FECA. If you are traveling for business purposes, you may be eligible for workers' compensation under state law.
If the accident occurs within the United States or its territories, or within U.S. airspace, or over the high seas, you and your
family may claim against the United States under the Federal Tort Claims Act or the Suits in Admiralty Act.

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Instructions: Please complete the form in either dark blue or black ink, or as a fillable pdf document. Please provide the form when
requested to the appropriate DHS or Department of State official.

NAME:

SSN/ITIN:

(please print)

EMAIL:

AGE/NATIONALITY:

CURRENT ADDRESS:

TELEPHONE NUMBER:
EMERGENCY POINT OF CONTACT NAME, ADDRESS & TEL. NO./EMAIL:

NAMES OF DEPENDENTS ON FLIGHT, IF ANY:

FLIGHT DATE:

AGE

FLIGHT NUMBER (if known):

FLIGHT DEPARTURE CITY/ARRIVAL CITY:
REASON FOR SPACE-AVAILABLE TRAVEL:

I agree to reimburse the Federal Government within 30 days of initial billing for the cost of full coach fare as set out in
applicable Federal authority. If I am unable to pay this amount in a lump sum, I will request an installment agreement to repay
the amount over time with interest at the applicable Treasury rate. I understand that my rights and responsibilities for
repaying the amount due for this flight will be set forth in full on a notice accompanying an invoice that will be sent to me to
collect the amount due.

SIGNATURE

ICE Form XXX (1/21)

DATE

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