Fillable Printable Form DS-3072
Fillable Printable Form DS-3072
Form DS-3072
49. Place of Birth
26. Address Line 2
25. Address Line 1
7. Identity Document
24. First Name
23. Last Name
(Print Clearly)
22. Emergency Contact
(Do not list someone traveling with you)
20. Telephone Number
(Include Country/City Codes)
21. E-mail Address
19. Postal Code
8. Sex
5. Date of Birth
6. Place of Birth
Male
Female
(mm-dd-yyyy)
4. Social Security Number
1. Last Name
2. First Name
3. Middle Name
(Print Clearly)
OR
12. Medical condition, current injuries, or limited mobility relevant to evacuation.
13. Verifiable Billing Address at Final Destination in United States or other Permanent Address
(Not a Post Office Box)
9. Current lodging where you may be contacted now .
10. Phone number where you may be contacted now.11. E-mail address where you may be contacted now.
16. City 17. State/Province
18. Country
27. City
28. State/Province
29. Country
31. Telephone Number 32. E-mail Address
30. Postal Code
33. Relationship to you
37. Middle Name
39. Date of Birth 40. Place of Birth41. Identity Document
38. Social Security
42. Sex
Male
Female
(mm-dd-yyyy)
35. Last Name
36. First Name
(Print Clearly)
43. This Person is My
46. Middle Name
48. Date of Birth 50. Identity Document
47. Social Security
51. Sex
Male
Female
(mm-dd-yyyy)
44. Last Name45. First Name
(Print Clearly)
52. This Person is My
OR
34. Minor Children or Incapacitated/Incompetent Adults to be Repatriated or to Receive Emergency Medical and Dietary Assistance, list below.
Check here if none
PART 1 - APPLICATION TO BE COMPLETED BY EACH ADULT APPLICANT REGARDLESS OF NATIONALITY
14. Address Line 1
15. Address Line 2
REPATRIATION / EMERGENCY MEDICAL AND DIETARY ASSISTANCE LOAN APPLICATION
U.S. Department of State
Evacuation From
to
on Date(DD-MMM-YYYY)
Page 1 of 3
OMB APPROVAL NO. 1405-0150
EXPIRATION DATE: 07/31/2020
ESTIMATED BURDEN: 20 MINUTES
DS-3072
06-2015
(Include Country/City Codes)
Issuing
Passport No.
National ID No.
Issuing Country
Passport No.
National ID No.
Issuing Country
Passport No.
National ID No.
OR
Number
Number
59. Identity Document
Issuing Country
Passport No.
OR
National ID No.
89. PART 2 - Promissory Note and Repayment Agreement
1. I promise to repay the U.S. Government in U.S. dollars or the foreign currency equivalent, within 30 days of initial billing, and if not repaid within 60 days of initial billing at
an interest rate established in accordance with Federal law, for Emergency, Medical and Dietary Assistance or Repatriation loans. This loan is in addition to any other
U.S. Government loans received for other purposes. I will keep the Department of State's Accounts Receivable Branch informed of my address(es) until I repay my loan in
full. If I am unable to pay this loan in full, the Department of State may, at its discretion and upon my request, forward to me an installment agreement containing an
installment plan for repayment of my loan.
2. I understand that:
(a) My obligation to repay my loan will not be considered paid in full until it clears through the account of the Treasurer of the United States.
(b) Until I have paid my loan in full, I and all listed U.S. citizen family members will only be eligible for a limited validity U.S. passport.
(c) If my loan is in default, I and all U.S. citizen listed family members will not be eligible for limited validity U.S. passports.
(d) My loan will be subject to interest, penalties, and other charges for late payment as directed by law and regulation.
(e) I will be liable to pay any costs for collection.
3. I will include my name, date of birth, place of birth, and Social Security number with all correspondence, payments, and questions. I will make payment to the
Department of State, Accounts Receivable by credit/debit card, check or money order payable to Accounts Receivable Branch, PO Box 979005, St. Louis, MO
63197-9000. (Send questions by mail to: Accounts Receivable Branch, Comptroller and Global Financial Services, Department of State, PO Box 150008, Charleston,
SC 29415-5008. Send questions by courier (DHL, Fedex, UPS, etc.) to: Accounts Receivable Branch, Comptroller and Global Financial Services 1969 Dyess Ave.,
Building 646-B, North Charleston, SC 29405. To make inquiries by telephone: From the U.S. or Canada, call: 1-800-521-2116 or internationally, call 843-746-0592.
To make inquiries by email, contact: [email protected].)
4. I understand that assistance requested from the Department of Health and Human Services (HHS) will be provided based on availability upon arrival in the United
States. In addition, reception and resettlement assistance provided by HHS is in the form of a loan which has to be paid back to the U.S. Government.
Page 2 of 3
55. Middle Name
53. Last Name
54. First Name
57. Date of Birth 58. Place of Birth
56. Social Security
60. Sex
Male
Female
(mm-dd-yyyy)
(Print Clearly)
61. This Person is My
64. Middle Name
66. Date of Birth 67. Place of Birth68. Identity Document
65. Social Security
69. Sex
Male
Female
(mm-dd-yyyy)
62. Last Name63. First Name
(Print Clearly)
70. This Person is My
73. Middle Name
75. Date of Birth 76. Place of Birth77. Identity Document
74. Social Security
78. Sex
Male
Female
(mm-dd-yyyy)
71. Last Name
72. First Name
(Print Clearly)
79. This Person is My
82. Middle Name
84. Date of Birth 85. Place of Birth86. Identity Document
83. Social Security
87. Sex
Male
Female
80. Last Name
81. First Name
(Print Clearly)
88. This Person is My:
Identity Document Number from Line 7
90. Signature Block for Applicant
91. Full Name Printed
92. Signature
93. Date
I hereby accept the foregoing terms and conditions of repayment for myself and persons listed.
(mm-dd-yyyy)
Number
Number
Issuing Country
Passport No.
OR
National ID No.
Number
Issuing Country
Passport No.
OR
National ID No.
(mm-dd-yyyy)
Number
Issuing Country
Passport No.
OR
National ID No.
100. If form is signed before Notary Public in the United States for benefit of unaccompanied minor child or incapacitated or incompetent adult abroad.
The above total includes U.S. Dollars currency for subsistence for the followng dates: and U.S. Dollars
currency for Repatriation/Emergency Medical and Dietary Assistance.
The undersigned consular officer approves the loan specified above.
PART 4 - CONSULAR OFFICER SIGNATURE AND CERTIFICATION
Signature of Consular Officer
Typed or Printed Name of Consular Officer
Title of Consular Officer
Name of Post
Date
SEAL
(mm-dd-yyyy)
If applicable, list U.S. citizen associated with Third Country National/Host Country National, accompanying spouse or partner, or escort of
primary applicant.
Name of the U.S. CitizenDate of BirthPlace of BirthSocial Security Number
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENT
AUTHORITY: The information on this form is requested under the authority of 22 U.S.C. ยงยง 2670, 2671 and E.O. 9397, as amended.
PURPOSE: The principal purpose of the information gathered is to provide an accurate list of U.S. citizens and non-U.S. citizens receiving
repatriation/emergency medical and dietary assistance in foreign countries.
ROUTINE USES: The information solicited on this form may be made available to other government agencies to assist the U.S. Department of
State in processing repatriation/emergency medical and dietary assistance documentation and related services, law enforcement and
administrative purposes. More information on the Routine Uses for the system can be found in System of Records Notice, State-05, Overseas
Citizens Services Records and the Prefatory Statement of Routine Uses published in the Federal Register.
DISCLOSURE: Furnishing the requested information is voluntary, but failure to provide it may result in delays in reviewing the application or
in an inability to provide the requested assistance.
PAPERWORK REDUCTION ACT (PRA) STATEMENT
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final
collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have
comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to:
U.S. Department of State, CA/OCS/L, SA-17, 10th Floor, Washington, DC 20522-1707.
Page 3 of 3
PART 3 - CONSULAR NOTES - For Official Use Only
No Signature of Loan Recipient - Minor
No Signature of Loan Recipient - Incapacitated/Incompetent Adult
Loan Includes Temporary Subsistence
No Social Security Number
Escort
Other
(No Familial Relationship)
(Please Explain)
Amount in U.S. Currency
Repatriation to United States or Emergency Medical or Dietary Assistance Abroad Loan Amount
Amount in Foreign Currency
I authorize the Department of State, including U.S. diplomatic and consular missions, to release information about me and persons listed to:
family, friends, individual members of
congress, members of the press, and the general public.
94. AUTHORIZATION FOR RELEASE OF INFORMATION UNDER THE PRIVACY ACT
96. Date
95. Signature
The Privacy Act authorization is optional and will not affect the Department of State's processing of your loan application.
(mm-dd-yyyy)
(Please place a check in the following boxes for the people to whom you authorize information to be released.)
Identity Document Number from Line 7
97. I authorize the Department of State to provide information to the U.S. Department of Health and Human Services (HHS) (Repatriation Program)
and/or its partners and grantees with information to assist in my/our resettlement if needed.
98. Signature
99. Date
(mm-dd-yyyy)
State ofCounty of On
Date
(mm-dd-yyyy)
, before me
(Notary)
Personally appeared,
(Signer)
Notary Public for My Commission Expires
(EMDA)
From(mm-dd-yyyy)
To(mm-dd-yyyy)
