View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1405-0211
ICR Reference No:
202509-1405-003
Status:
Active
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
OIRA Conclusion Action:
Approved without change
Conclusion Date:
12/19/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
09/18/2025
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2027
06/30/2027
06/30/2027
Responses
525
0
1,050
Time Burden (Hours)
175
0
350
Cost Burden (Dollars)
0
0
0
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.
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
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
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
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
ICR Summary of Burden
Total Approved
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:
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
Agency Contact:
Thales Dus 202 485-6725
Common Form ICR:
No
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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