Information Collection

Eligibility Questionnaire For HAVANA Act Payments

IC 253057 under ICR 202601-1405-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Eligibility Questionnaire For HAVANA Act Payments Form and Instruction
Form DS-4316 Eligibility Questionnaire for HAVANA Act payments Eligibility Questionnaire For HAVANA Act Payments Form
DS-4316 Eligibility Questionnaire for Havana Act Payments DS-4316 Updated.pdf eforms.state.gov Form and Instruction
DS-4316 Eligibility Questionnaire for HAVANA Act payments DS4316 - DRAFT - 12-22-2025.pdf eforms.state.gov Form

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? Yes		IC Status: Modified

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 Updated.pdf	eforms.state.gov	Yes	No	Fillable Printable
Form	DS-4316	Eligibility Questionnaire for HAVANA Act payments	DS4316 - DRAFT - 12-22-2025.pdf	https://eforms.state.gov	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: STATE-31 Human Resources Records	FR Citation: 78 FR 43258

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

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
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.

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