Form DS-5528 Evacuee Manifest and Promissory Note

U.S. Department of State

OMB APPROVAL - NO.1405-0211
EXPIRATION DATE: 05-31-2017
ESTIMATED BURDEN: 20 Minutes

EVACUEE MANIFEST AND PROMISSORY NOTE

PART 1 - EVACUATION APPLICATION TO BE COMPLETED BY EACH ADULT APPLICANT REGARDLESS OF NATIONALITY
1. Last Name (Print Clearly)

4. Social Security Number

2. First Name

3. Middle Name

5. Date of Birth
6. Place of Birth
(DD-MMM-YYYY)

7. Identity Document
Issuing Country

8. Sex
Male

Passport Number
Female

or National ID No.
9. Current lodging where you may be contacted now
10. Phone number where you may be contacted now

11. Email address where you may be contacted now

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) (Third Party Contractors
must complete. Not applicable to U.S. Government employees on official assignment and/or Eligible Family Members )
14. Address Line 1
15. Address Line 2
16. City

18. Country

17. State/Province

19. Postal Code

20. Telephone Number (Include Country/City Codes)

21. Email Address

22. Emergency Contact (Do not list someone traveling with you)
24. First Name

23. Last Name (Print Clearly)
25. Address Line 1
26. Address Line 2
27. City

28. State/Province

30. Postal Code

29. Country

31. Telephone Number (Include Country/City Codes)

32. Email Address

33. Relationship to you

34. Accompanying Minor Children or Incapacitated/Incompetent Adults Only, list below.
35. Last Name (Print Clearly)

38. Social Security
Number

39. Date of Birth
(DD-MMM-YYYY)

36. First Name

40. Place of Birth

Check here if none
37. Middle Name

41. Identity Document
Issuing Country

42. Sex

43. This Person is My:

Male

Passport No.
Female

or National ID No.
44. Last Name (Print Clearly)

47. Social Security
Number

48. Date of Birth
(DD-MMM-YYYY)

45. First Name

49. Place of Birth

46. Middle Name

50. Identity Document
Issuing Country

51. Sex

52. This Person is My:

Male

Passport No.
or National ID No.
DS-5528
04-2016

Female
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Identity Document Number from Line 7
53. Last Name (Print Clearly)

56. Social Security
Number

57. Date of Birth
(DD-MMM-YYYY)

54. First Name

58. Place of Birth

55. Middle Name

59. Identity Document

60. Sex

Issuing Country

61. This Person is My:

Male

Passport No.
OR

62. Last Name (Print Clearly)

65. Social Security
Number

66. Date of Birth
(DD-MMM-YYYY)

63. First Name

67. Place of Birth

Female

National ID No.
64. Middle Name

68. Identity Document
Issuing Country

69. Sex

70. This Person is My:

Male

Passport No.
OR

71. Last Name (Print Clearly)

74. Social Security
Number

75. Date of Birth
(DD-MMM-YYYY)

72. First Name

76. Place of Birth

Female

National ID No.
73. Middle Name

77. Identity Document
Issuing Country

78. Sex

79. This Person is My:

Male

Passport No.
OR

80. Last Name (Print Clearly)

83. Social Security
Number

84. Date of Birth
(DD-MMM-YYYY)

81. First Name

85. Place of Birth

Female

National ID No.
82. Middle Name

86. Identity Document
Issuing Country

87. Sex

88. This Person is My:

Male

Passport No.
OR

National ID No.

Female

89. PART 2 - Promissory Note and Repayment Agreement (FOR ALL EVACUEES, including Third Party Contractors. Not Applicable to U.S.
Government employees on official assignment and/or Eligible Family Members.)
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: FMPARD@state.gov.)

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.

90. Signature Block for Applicant (Not Applicable to U.S. Government employees on official assignment and/or Eligible Family Members.
Third Party Contractors must complete.)
I hereby accept the foregoing terms and conditions of repayment for myself and persons listed. I understand that refusal to sign does not relieve me
of my debt if the persons listed used the transport.
91. Full Name Printed
92. Signature
DS-5528

93. Date (DD-MMM-YYYY)
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Identity Document Number from Line 7

PART 3 - CONSULAR NOTES - For Official Use Only
No Signature of Loan Recipient - Minor

No Social Security Number

No Signature of Loan Recipient - Incapacitated/Incompetent Adult

Escort of the Primary Applicant (No Familial Relationship)

Loan Includes Temporary Subsistence Associated with Evacuation

Other (Please Explain)

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

FOR OFFICIAL USE ONLY TO BE COMPLETED BY U.S. CONSULAR OFFICER (Insert number of individuals for each category)
Transport Number

U.S. Citizen Loan Recipient

Legal Permanent
Resident Loan Recipient

Transport Type

Third Country or Host Country
National Loan Recipient

Foreign Diplomat Loan Recipient

Evacuation from

USG Employee/EFM
on Official Assignment

on date (DD-MMM-YYYY)

to

PART 4 - CONSULAR OFFICER SIGNATURE AND CERTIFICATION
The undersigned consular officer approves the loan specified above and certifies the persons listed boarded the transport.

Name of Post

Signature of Consular Officer

Typed or Printed Name of Consular Officer

Date (DD-MMM-YYYY)

Title of Consular Officer

94.

SEAL

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,
members of congress,
members of the press,
and the general public.
95. Signature

individual

96. Date (DD-MMM-YYYY)
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENT

AUTHORITY: The information on this form is requested under the authority of 22 U.S.C. § 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.
DS-5528

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