Email to (one or more addresses, comma-separated; leave blank to only download)

Flight details (optional operator fields)

Tail

Flight date

Departure airport

Arrival airport

Tail + flight date + departure airport give the subject "CDC Attestation – tail – date – airport"; otherwise "CDC Attestation – traveler – signature date".

OMB Control No: 0920-1474 Expiration Date: 3/31/2027

ATTACHMENT A
TRAVELER DISCLOSURE AND ATTESTATION
TO THE UNITED STATES OF AMERICA

All airlines or other aircraft operators covered by the Order must provide the following disclosure and attestation form to all persons intending to board any aircraft destined for the United States from a foreign country and confirm completion of the disclosure and attestation form prior to embarkation.

TRAVELER ATTESTATION REQUIREMENT:

I [name of traveler or authorized representative, the “Attestee”] Role on this flight

have read the following disclosure pertaining to not having been present in the Democratic Republic of the Congo in the past 21 days. Presence in the Democratic Republic of the Congo means any physical presence, including entering or traveling through the country by air (excluding overflights), land, or sea. Presence also includes connecting through an airport in the Democratic Republic of the Congo, even if the traveler did not disembark the plane or leave the airport.

Check exactly one of the options below:

I attest that I have not been present in the Democratic Republic of the Congo in the past 21 days prior to boarding a flight to the United States. On behalf of (the Attestee), for whom I am authorized to act, I attest that such person has not been present in the Democratic Republic of the Congo in the past 21 days preceding boarding a flight to the United States.

Airline or aircraft operator personnel may assist with data entry but do not attest on behalf of the Attestee.

I attest that I have responded truthfully and understand that willfully providing false or misleading information may lead to criminal fines and imprisonment under 18 U.S.C. § 1001, and that I may be subject to criminal penalties under 42 U.S.C. § 271 and 42 C.F.R. §71.2, in conjunction with 18 U.S.C. §§ 3559 and 3571 for failure to comply with these requirements. Printed Name of Traveler or Authorized Representative Signature (sign with your finger)

Date

Airline and aircraft operator disclosure requirement & Privacy Act Statement

The full CDC text (pages 1–2 of Attachment A) is included unchanged in the PDF, which is generated by filling the official CDC fillable form and then flattened (not editable). Operators must collect and retain the completed attestation for at least 42 days and provide it to the U.S. Government upon request. Each individual must provide a separate attestation.