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OMB Control No: 1405-0259	ICR Reference No: 202607-1405-004
Status: Received in OIRA	Previous ICR Reference No: 202506-1405-002
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Crisis Assistance Request Form - (Dept. of State)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 07/20/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	09/30/2026
Responses	120,000	120,000
Time Burden (Hours)	10,000	10,000
Cost Burden (Dollars)	243,600	243,600

Annual Cost to Federal Government: $0

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: Monica Gaw 202 736-9107 GAWMA@state.gov

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