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Please place a check in each box that applies.
I am permanently a resident in
I am temporarily a resident in until
I travel to and from several times a year.
Signature, or Typed Name if Submitted by Email
AUTHORITY: The information on this form is requested under the authority of 22 U.S.C. §
4802(b), 31 U.S.C. § 1342, 22 CFR § 71.1 and 22 CFR § 71.6.
PURPOSE: The principal purpose of gathering this information is to identify U.S. citizens residing
in a particular country who may possess critical skills and resources invaluable for helping other
Americans in a time of crisis. Absent your prior written consent, no information on this form may be
disclosed to any persons or agency unless such a disclosure would be permitted by the Privacy
Act, 5 USC552a (b) ("Conditions of disclosure").
ROUTINE USES: The information on this form may be shared with federal, state, and local
government agencies; members of Congress; officials of foreign governments; U.S. and foreign
courts; U.S. and foreign nongovernmental organizations, including disaster or emergency relief
organizations such as the International Red Cross, Red Crescent and others. This information
collection is covered by the System of Records Notice.
Responding to this survey is purely voluntary.
Public reporting burden for this collection of information is estimated to average 15 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/PMO, U.S. Department of State,
SA-17, 10th Floor, Washington, DC 20522-1707.
PRIVACY ACT STATEMENT
PAPERWORK REDUCTION ACT (PRA) STATEMENT