Form Ds-3072 - Repatriation / Emergency Medical And Dietary Assistance Loan Application - U.s. Department Of State Page 2

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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.

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.

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.

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.

Female

National ID No.

89. PART 2 - Promissory Note and Repayment Agreement

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.

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.

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.)

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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