Evacuee Manifest and Promissory Note

Forms and Documents

Document Name	Status
Form DS-5528 Evacuee Manifest and Promissory Note Form and Instruction	New
Form DS-5528 Evacuee Manifest and Promissory Note Form and Instruction	Removed
Form DS-5528 Evacuee Manifest and Promissory Note Form and Instruction	Removed
Justification for Change to DS- 5528 - 1405-0211.docx Justification for No Material/Nonsubstantive Change	2025-09-18
ds5528 - DRAFT - 06-06-2024.pdf Justification for No Material/Nonsubstantive Change	2024-06-13
Justification for Non-substantive change.docx Justification for No Material/Nonsubstantive Change	2024-06-13
5528 langauge.docx Supplementary Document	2024-04-15
2024 04 04 Answers to OIRA 2020 Questions DS 5528 Supporting Statement.docx Supplementary Document	2024-04-15
2024 04 04 Supporting Statement Updated.docx Supporting Statement A	2024-04-15
Final Legal Authorities DS-5528.docx Supplementary Document	2017-05-05

IC Document Collections

IC ID	Document Title	Status
277600	Evacuee Manifest and Promissory Note Form and Instruction	New
266921	Evacuee Manifest and Promissory Note Form and Instruction	Removed
206882	Evacuee Manifest and Promissory Note Form and Instruction	Removed

ICR Details

OMB Control No: 1405-0211	ICR Reference No: 202509-1405-003
Status: Received in OIRA	Previous ICR Reference No: 202406-1405-005
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Evacuee Manifest and Promissory Note
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/18/2025

	Requested	Previously Approved
Expiration Date	06/30/2027	06/30/2027
Responses	525	1,050
Time Burden (Hours)	175	350
Cost Burden (Dollars)	0	0

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Abstract: The DS 5528, Evacuee Manifest and Promissory Note, is used to document the evacuation of persons from abroad when their lives are endangered by war, civil unrest, or natural disaster; document issuance of a crisis evacuation loan; to obtain a Privacy Act waiver to share information about the welfare of a citizen or lawful permanent resident with designated persons; and to facilitate debt collection.

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Authorizing Statute(s): US Code: 22 USC 4802 Name of Law: Responsibility of the Secretary of State
   US Code: 22 USC 2715 Name of Law: Procedures regarding major disasters and incidents abroad affecting United States Citizens
   US Code: 22 USC 2671 Name of Law: Emergency Expenditures
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 29775	05/18/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 46208	07/31/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Evacuee Manifest and Promissory Note	DS-5528, Old DS-5528	Evacuee Manifest and Promissory Note ,   Evacuee Manifest and Promissory Note
Evacuee Manifest and Promissory Note	DS-5528	EVACUEE MANIFEST AND PROMISSORY NOTE
Evacuee Manifest and Promissory Note	DS-5528, DS-5528	Evacuee Manifest and Promissory Note ,   Evacuee Manifest and Promissory Note

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	525	1,050	0	0	-525	0
Annual Time Burden (Hours)	175	350	0	0	-175	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $10,395

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/18/2025

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