89. PART 2 - Promissory Note and Repayment Agreement
Government employees on official assignment and/or Eligible Family Members.)
(FOR ALL EVACUEES, including Third Party Contractors. Not Applicable to U.S.
1.
2.
3.
4.
5.
Page 2 of 3
55. Middle Name
53. Last Name
54. First Name
57. Date of Birth 58. Place of Birth 59. Identity Document
56. Social Security
Number
60. Sex
Male
Female
(DD-MMM-YYYY)
(Print Clearly)
61. This Person is My:
64. Middle Name
66. Date of Birth 67. Place of Birth 68. Identity Document
65. Social Security
Number
69. Sex
Male
Female
(DD-MMM-YYYY)
62. Last Name 63. First Name
(Print Clearly)
70. This Person is My:
73. Middle Name
75. Date of Birth 76. Place of Birth 77. Identity Document
74. Social Security
Number
78. Sex
Male
Female
(DD-MMM-YYYY)
71. Last Name
72. First Name
(Print Clearly)
79. This Person is My:
82. Middle Name
84. Date of Birth 85. Place of Birth 86. Identity Document
83. Social Security
Number
87. Sex
Male
Female
(DD-MMM-YYYY)
80. Last Name
81. First Name
(Print Clearly)
88. This Person is My:
Issuing Country
Passport No.
National ID No.
OR
Issuing Country
Passport No.
National ID No.
OR
Issuing Country
Passport No.
National ID No.
OR
Issuing Country
Passport No.
National ID No.
OR
Identity Document Number from Line 7
90. Signature Block for Applicant
91. Full Name Printed
92. Signature
93. Date
(Not Applicable to U.S. Government employees on official assignment and/or Eligible Family Members.
of my debt if the persons listed used the transport.
I hereby accept the foregoing terms and conditions of repayment for myself and persons listed.
(DD-MMM-YYYY)
Third Party Contractors must complete.)
I understand that refusal to sign does not relieve me
DS-5528
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.
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.
I understand that:
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 or courier (DHL, FedEx, UPS, etc.) to: Accounts Receivable Branch, Comptroller and Global Financial Services, Department of
State, 2010 Bainbridge Ave., 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 inquires by email, contact: FMPARD@state.gov).
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.
(a)
(b)
(c)
(d)
(e)
(f)
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.
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.
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.
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.
My loan will be subject to interest, penalties, and other charges for late payment as directed by law and regulation.
I will be liable to pay any costs for collection.
