Form Ds-3072 - Repatriation / Emergency Medical And Dietary Assistance Loan Application - U.s. Department Of State Page 3
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1
2
3Identity Document Number from Line 7
94.
AUTHORIZATION FOR RELEASE OF INFORMATION UNDER THE PRIVACY ACT
The Privacy Act authorization is optional and will not affect the Department of State's processing of your loan application.
I authorize the Department of State, including U.S. diplomatic and consular missions, to release information about me and persons listed to:
(Please place a check in the following boxes for the people to whom you authorize information to be released.)
family,
friends,
individual
members of congress,
members of the press,
and the general public.
96. Date
(mm-dd-yyyy)
95. Signature
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.
99. Date
(mm-dd-yyyy)
98. Signature
100. If form is signed before Notary Public in the United States for benefit of unaccompanied minor child or incapacitated or incompetent adult abroad.
State of
County of
On
, before me
(mm-dd-yyyy)
(Notary)
Date
Personally appeared,
Notary Public for My Commission Expires
(Signer)
PART 3 - CONSULAR NOTES - For Official Use Only
No Social Security Number
No Signature of Loan Recipient - Minor
(No Familial Relationship)
No Signature of Loan Recipient - Incapacitated/Incompetent Adult
Escort
Other
(Please Explain)
Loan Includes Temporary Subsistence
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. Citizen
Date of Birth
Place of Birth
Social Security Number
Repatriation to United States or Emergency Medical or Dietary Assistance Abroad
(EMDA)
Loan Amount
Amount in Foreign Currency
Amount in U.S. Currency
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.
From (mm-dd-yyyy)
To (mm-dd-yyyy)
PART 4 - CONSULAR OFFICER SIGNATURE AND CERTIFICATION
The undersigned consular officer approves the loan specified above.
Name of Post
Signature of Consular Officer
Typed or Printed Name of Consular Officer
Date
(mm-dd-yyyy)
SEAL
Title of Consular Officer
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENT
AUTHORITY: The information on this form is requested under the authority of 22 U.S.C. §§ 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
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