Privacy Act Statement

Privacy Act Statement

AUTHORITIES: The information on this form is requested pursuant to Executive Order 12656 (Assignment of emergency preparedness responsibilities) and U.S. Department of State authorities providing for consular and emergency assistance and visa functions, including 22 U.S.C. § 4802(b) (Overseas evacuations), the Vienna Convention on Consular Relations and 22 U.S.C. § 3904 (Functions of Service), 22 U.S.C. § 2671 (Emergency Expenditures), 22 U.S.C. § 2656 (Management of Foreign Affairs) and in 8 U.S.C. § 1101 et seq. (U.S. Immigration and Nationality Act) (INA).

PURPOSE: The requested information will be used to assist the United States government in coordinating and conducting the evacuation of U.S. citizens and others in light of the current crisis situation in the country, and in facilitating onward transportation and assistance where applicable.

ROUTINE USES: The information on this form may be, in connection with the consular functions requested, shared with other U.S. or foreign government authorities, airlines and other transportation carriers, international or non-governmental organizations, and others. More information on the routine uses for the system can be found in System of Records Notices STATE-05, Overseas Citizen Services Records and other Overseas Records. In an emergency situation such recipients may extend beyond those listed if they are in a position to assist, and your submission indicates your consent to the Department sharing for such purposes.

DISCLOSURE: Providing this information is voluntary, however without it the United States government will be constrained in efforts to provide appropriate assistance. All information will be handled in accordance with the Privacy Act (5 U.S.C. § 552a) and the visa confidentiality provisions of the INA (8 U.S.C. § 1202(f)), as applicable.

If you are submitting information about individuals other than yourself or your minor children, please be aware that the Department of State may be limited in some circumstance in what it can share unless those individuals also provide their written consent.

SENSITIVE BUT UNCLASSIFIED