Fillable Printable Form DS-5528
Fillable Printable Form DS-5528
Form DS-5528
Issuing Country
50. Identity Document
or National ID No.
Passport No.
Issuing Country
41. Identity Document
or National ID No.
Passport No.
7. Identity Document
or National ID No.
Passport Number
Issuing Country
4. Social Security Number
24. First Name
23. Last Name
(Print Clearly)
22. Emergency Contact
(Do not list someone traveling with you)
20. Telephone Number
21. Email Address
19. Postal Code
8. Sex
5. Date of Birth
6. Place of Birth
Male
Female
(DD-MMM-YYYY)
1. Last Name
2. First Name
3. Middle Name
(Print Clearly)
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
must complete. Not applicable to U.S. Government employees on official assignment and/or Eligible Family Members )
10. Phone number where you may be contacted now 11. Email 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. Email Address
30. Postal Code
33. Relationship to you
37. Middle Name
34. Accompanying Minor Children or Incapacitated/Incompetent Adults Only, list below. Check here if none
39. Date of Birth 40. Place of Birth
38. Social Security
Number
42. Sex
Male
Female
(DD-MMM-YYYY)
35. Last Name 36. First Name
(Print Clearly)
43. This Person is My:
46. Middle Name
48. Date of Birth 49. Place of Birth
47. Social Security
Number
51. Sex
Male
Female
(DD-MMM-YYYY)
44. Last Name 45. First Name
(Print Clearly)
52. This Person is My:
25. Address Line 1
PART 1 - EVACUATION APPLICATION TO BE COMPLETED BY EACH ADULT APPLICANT REGARDLESS OF NATIONALITY
EVACUEE MANIFEST AND PROMISSORY NOTE
U.S. Department of State
Evacuation From
to
on Date (DD-MMM-YYYY)
Page 1 of 3
14. Address Line 1
15. Address Line 2
26. Address Line 2
(Third Party Contractors
DS-5528
04-2016
OMB APPROVAL - NO.1405-0211
EXPIRATION DATE: 07-31-2020
ESTIMATED BURDEN: 20 Minutes
(Include Country/City Codes)
(Include Country/City Codes)
59. Identity Document
Passport No.
Issuing Country
or National ID No.
89. PART 2 - Promissory Note and Repayment Agreement
Government employees on official assignment and/or Eligible Family Members.)
(FOR ALL EVACUEES, including Third Party Contractors. Not Applicable to U.S.
1. I clearly understand that I am accepting evacuation of my own free will and at my own risk to a location chosen by the U.S. Government. The mode of transportation may
be via charter or military transport. I also understand that the evacuation flight may not comply with normal international safety or luggage/cargo regulations/standards.
In the case of military aircraft travel, the U.S. Government acts only as an agent and not as a contract carrier.
2. U.S. Citizens: 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 all applicable expenses for my/our evacuation. This evacuation 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.
3. I understand that:
(a) I will be billed for the cost of my/our transportation no greater than the amount of a full-fare economy flight, or comparable alternate transportation, to the
designated destination(s) that would have been charged immediately prior to the events giving rise to the evacuation.
(b) 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.
(c) 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.
(d) If my loan is in default, I and all listed U.S. citizen family members will not be eligible for a limited validity U.S. passports.
(e) My loan will be subject to interest, penalties, and other charges for late payment as directed by law and regulation.
(f) I will be liable to pay any costs for collection.
4. 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].)
5. Non U.S. Citizens: I understand that my government and the United States will determine the amount I owe and means of repayment. My government may seek
reimbursement from me for the cost of my/our evacuation.
Page 2 of 3
55. Middle Name
53. Last Name
54. First Name
57. Date of Birth 58. Place of Birth
56. Social Security
Number
60. Sex
Male
Female
(DD-MMM-YYYY)
(Print Clearly)
61. This Person is My:
64. Middle Name
66. Date of Birth 67. Place of Birth 68. Identity Document
65. Social Security
Number
69. Sex
Male
Female
(DD-MMM-YYYY)
62. Last Name 63. First Name
(Print Clearly)
70. This Person is My:
73. Middle Name
75. Date of Birth 76. Place of Birth 77. Identity Document
74. Social Security
Number
78. Sex
Male
Female
(DD-MMM-YYYY)
71. Last Name
72. First Name
(Print Clearly)
79. This Person is My:
82. Middle Name
84. Date of Birth 85. Place of Birth 86. Identity Document
83. Social Security
Number
87. Sex
Male
Female
(DD-MMM-YYYY)
80. Last Name
81. First Name
(Print Clearly)
88. This Person is My:
Issuing Country
Passport No.
or National ID No.
Issuing Country
Passport No.
or National ID No.
Issuing Country
Passport No.
or National ID No.
Identity Document Number from Line 7
90. Signature Block for Applicant
91. Full Name Printed
92. Signature
93. Date
(Not Applicable to U.S. Government employees on official assignment and/or Eligible Family Members.
of my debt if the persons listed used the transport.
I hereby accept the foregoing terms and conditions of repayment for myself and persons listed.
(DD-MMM-YYYY)
Third Party Contractors must complete.)
I understand that refusal to sign does not relieve me
DS-5528
I authorize the Department of State, including U.S. diplomatic and consular missions, to release information about me and persons listed to:
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.
(DD-MMM-YYYY)
(Please place a check in the following boxes for the people to whom you authorize information to be released.)
The undersigned consular officer approves the loan specified above and certifies the persons listed boarded the transport.
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
(DD-MMM-YYYY)
If applicable, List below U.S. citizen associated with Third Country National/Host Country National, accompanying spouse or partner, or escort
primary applicant.
Name of the U.S. Citizen Date of Birth Place of Birth Social Security Number
U.S. Citizen Loan Recipient
Third Country or Host Country
National Loan Recipient
USG Employee/EFM
on Official Assignment
Transport Number
Foreign Diplomat Loan Recipient
FOR OFFICIAL USE ONLY TO BE COMPLETED BY U.S. CONSULAR OFFICER
Evacuation from
to
on date (DD-MMM-YYYY)
Transport Type
Legal Permanent
Resident Loan Recipient
(Insert number of individuals for each category)
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 Associated with Evacuation
No Social Security Number
Escort of the Primary Applicant
Other
(No Familial Relationship)
(Please Explain)
Identity Document Number from Line 7
DS-5528
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENT
AUTHORITY: The information on this form is requested under the authority of 22 U.S.C. ยง 2671, 2715, 4802, and 2357; 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 being
evacuated from foreign countries in times of crisis. The information will also assist in collection of expenses incurred by the U.S.
Government for evacuations.
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 emergency loan and evacuation documentation and related services and for law enforcement and administrative
purposes. Also see the Department of State's routine uses for 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:
CA/OCS/L, 4th Floor, SA-29, U.S. Department of State, Washington, DC 20522-2202.
family, friends, individual
members of congress, members of the press, and the general public.
