Repatriation/Emergency Medical and Dietary Assistance Loan Application

Forms and Documents

Document Name	Status
Form DS-3072 Repatriation/Emergency Medical and Dietary Assistance Loan Application Form and Instruction	Modified
Legal Authorities (4-2015).docx Supplementary Document	2015-04-14
Supporting Statement (5-2015 rev).docx Supporting Statement A	2015-05-27

IC Document Collections

IC ID	Document Title	Status
15037	Repatriation/Emergency Medical and Dietary Assistance Loan Application Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0150	ICR Reference No: 201504-1405-002
Status: Historical Active	Previous ICR Reference No: 201305-1405-001
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Repatriation/Emergency Medical and Dietary Assistance Loan Application
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/01/2015
	Date Received in OIRA: 04/14/2015
Terms of Clearance: Approved for two years only due to lack of GPEA compliance. This form cannot be submitted online.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	36 Months From Approved	06/30/2015
Responses	1,446	0	1,357
Time Burden (Hours)	482	0	452
Cost Burden (Dollars)	38,256	0	86,750

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Abstract: The DS-3072 is an application for an emergency loan for a destitute U.S. citizen and/or eligible family member to return to the United States, an application for a destitute U.S. citizen and/or eligible family member abroad to receive emergency medical and dietary assistance, and an application for a U.S. citizen and/or and/or eligible family member to receive a loan to assist in his or her repatriation to the United States, and/or to provide them with the funds needed to address their emergency medical and/or dietary needs.

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Authorizing Statute(s): US Code: 22 USC 2670 Name of Law: Responsibility of Secretary of State
   US Code: 22 USC 2671 Name of Law: Emergency expenditures
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 2770	01/20/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 20061	04/14/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Repatriation/Emergency Medical and Dietary Assistance Loan Application	DS-3072	Repatriation/Emergency Medical and Dietary Assistance Loan Application

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,446	1,357	0	0	89	0
Annual Time Burden (Hours)	482	452	0	0	30	0
Annual Cost Burden (Dollars)	38,256	86,750	0	0	-48,494	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Burden changes are due to an increase in respondents and a more accurate estimation of submission costs for this collection.

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Annual Cost to Federal Government: $39,633

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/14/2015

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