Identity Document Number from Line 7
54. First Name
53. Last Name
(Print Clearly)
55. Middle Name
56. Social Security
57. Date of Birth
58. Place of Birth
59. Identity Document
60. Sex
61. This Person is My
Number
(mm-dd-yyyy)
Issuing Country
Male
Passport No.
OR
Female
National ID No.
(Print Clearly)
62. Last Name
63. First Name
64. Middle Name
65. Social Security
69. Sex
70. This Person is My
66. Date of Birth
67. Place of Birth
68. Identity Document
(mm-dd-yyyy)
Number
Issuing Country
Male
Passport No.
OR
Female
National ID No.
71. Last Name
(Print Clearly)
72. First Name
73. Middle Name
74. Social Security
75. Date of Birth
76. Place of Birth
77. Identity Document
78. Sex
79. This Person is My
(mm-dd-yyyy)
Number
Issuing Country
Male
Passport No.
OR
Female
National ID No.
(Print Clearly)
80. Last Name
81. First Name
82. Middle Name
83. Social Security
87. Sex
88. This Person is My:
84. Date of Birth
85. Place of Birth
86. Identity Document
Number
(mm-dd-yyyy)
Issuing Country
Male
Passport No.
OR
Female
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: FMPARD@state.gov.)
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.
90. Signature Block for Applicant
I hereby accept the foregoing terms and conditions of repayment for myself and persons listed.
91. Full Name Printed
92. Signature
(mm-dd-yyyy)
93. Date
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