Information Collection

Eligibility Questionnaire For HAVANA Act Payments

IC 253057 under ICR 202204-1405-006 · OMB 1405-0250.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0250 can be found here:

Documents and Forms

Document Name Document Type
Form DS-4316 Eligibility Questionnaire For HAVANA Act Payments Form and Instruction
DS-4316 Eligibility Questionnaire for HAVANA Act Payments ds4316.pdf eforms.state.gov Form and Instruction
DS-4316 Eligibility Questionnaire for HAVANA Act Payments DS-4316 Final 6-21-2022.pdf eforms.state.gov Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Eligibility Questionnaire For HAVANA Act Payments	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 22 CFR 135

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-4316	Eligibility Questionnaire for HAVANA Act Payments	DS-4316 Final 6-21-2022.pdf	eforms.state.gov	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.