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OMB Control No: 1405-0223	ICR Reference No: 202604-1405-003
Status: Received in OIRA	Previous ICR Reference No: 201912-1405-004
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Adoption Family Relief Act Refund Application
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 04/20/2026

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	20	0
Time Burden (Hours)	2	0
Cost Burden (Dollars)	94	0

Annual Cost to Federal Government: $758

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: Robert Schlicht 202 486-6685 schlichtrr@state.gov

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