Form 1 Request for Assistance

OMB Control Number: 0970-0362
Expiration Date: 10/31/2012

U.S. Department of Health and Human Services
Administration for Children and Families
Office of Refugee Resettlement
Anti-Trafficking in Persons Division
Request for Assistance for Child Victims of Human Trafficking
This form may be used to request eligibility for federally funded assistance for a child victim of human
trafficking.
An individual may use this form to request eligibility for assistance for a non-U.S. Citizen, non-Lawful Permanent Resident (LPR)
child (under the age of 18) in the United States if the requestor believes the child may have been subjected to a severe form of
trafficking in persons, as defined by the Trafficking Victims Protection Act of 2000, as amended (TVPA). The TVPA directs the
Secretary of HHS, upon receipt of credible information that a child who is seeking assistance may have been subjected to a
severe form of trafficking in persons, to promptly determine if the child is eligible for interim assistance for a period of up to 90
days.
The purpose of this form is to notify ORR of a child seeking assistance who is a potential victim of a severe form of trafficking in
persons and to provide information to assist ORR in making a prompt determination of the child's eligibility for interim
assistance. Information provided in the form may also facilitate a determination by ORR of the child's eligibility for assistance as
a victim of a severe form of trafficking in persons. In some cases it may be possible for ORR to determine promptly that a child
has been subjected to a severe form of trafficking in persons without first making the child eligible for interim assistance.
ORR recognizes that requestors encounter child victims at various stages of escaping the trafficking situation and that
information may be limited. Therefore, the form has two sections: Part 1 and Part 2. ORR recommends submitting the form
in its entirety. However, if a requestor working with a potential child victim of trafficking anticipates that forthcoming
information will demonstrate the child has been subjected to a severe form of trafficking, the requestor may wish to submit Part
2 separately.
A requestor may submit this form by e-mail to [email protected] or by fax to 202-401-5487. An individual may
also request assistance for a potential child victim of trafficking by calling 202-205-4582 during regular business hours and
speaking to an ORR Child Protection Specialist.
An ORR Child Protection Specialist will respond to the requestor upon receipt of this form and provide the requestor with an
update on the status within 10 business days. If within 30 calendar days of receipt of the request ORR has not received credible
information that a child may have been subjected to a severe form of trafficking in persons, ORR will issue a denial letter to the
requestor. The requestor may appeal a denial of eligibility for assistance within 30 days of receipt of the decision. Instructions
on the appeal process are included with the denial letter. Should additional information become available, the requestor can
submit a new request for assistance ORR.
Use of this form, or the completion of any section of the form, is optional. ORR recommends submission of the
form to facilitate ORR's review of information indicating that a child needing assistance may have been subjected to trafficking in
persons and to assess potential child protection issues, particularly for unaccompanied children.
If you would like assistance in assessing the needs of a potential child victim of trafficking before submitting a request for
assistance, an ORR Child Protection Specialist can provide technical assistance and refer you to a local service provider upon
request. The National Human Trafficking Resource Center at 1-888-3737-888 is also available 24 hours a day, 7 days a week to
help you with technical assistance and referrals.

U.S. Department of Health and Human Services
Administration for Children and Families
Office of Refugee Resettlement
Anti-Trafficking in Persons Division

OMB Control Number: 0970-0362
Expiration Date: 10/31/2012

Requestor Information (Person Completing Form)
The Requestor Information informs HHS about the requestor's professional association. HHS may request
further information regarding the requestor or organizational credentials.
Name of Requestor
Last

Middle/Other

First

Title
Address
Phone

City

State

Fax

Zip Code

Other Phone

Email
Name of Organization/Agency

Address

City

State

Zip Code

Child's Information
Child's Name
Last

First

Middle/Other

Country of Origin

Specific Location of Origin (i.e. town, state)

Child's Date of Birth (MM/DD/YYYY)

Child's Sex

Male

Female

If the child has an alien number, please provide:
Proof of Citizenship and Age
If the child has identifying documents (e.g., passport, birth
certificate, immigration documents), attach copies. If the child
does not have identifying documents, provide explanation.

Does the child have a parent or parents in the U.S.?

Yes

No

Attorney of record, for the child, if any, and attorney's
contact information:
Sex Traffiicking
Information indicates that the child was subjected to:

Labor Traffiicking
Both

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Narrative Describing Indicators of Trafficking
The requestor should provide a narrative describing the elements of trafficking present in the case including: the actions
(recruitment, harboring, transportation, provision, or obtaining), the means (force, fraud, or coercion), and the end (purpose
of subjection to involuntary servitude, peonage, debt bondage, or slavery) for a labor trafficking case, or, indicators of
commercial sex if a sex trafficking case. If known, the requestor may discuss in greater detail the time frame, duration, and
location of the trafficking; how, when, and where the child was first identified as a potential victim of human trafficking; how
and when this child came to requestor's attention; whether the trafficking situation was reported to local or State Child
Protective Services (CPS) and related follow-up action, if any; and whether the trafficking situation was reported to local,
State, or Federal law enforcement and related follow-up action, if any.
When screening a potential child trafficking victim, a requestor should refer to the federal definition of a severe form of
trafficking in persons, as laid out in the Trafficking Victims Protection Act (TVPA) of 2000, as amended.
1. Severe form of trafficking in persons means:
- Sex trafficking in which…the person induced to perform a commercial sex act has not attained 18 years of age; or
- “The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use
of force fraud or coercion, for the purpose of subjection to involuntary servitude, peonage, debt bondage, or
slavery.” (22 U.S.C. § 7102 (8)).
2. Sex trafficking means “recruitment, harboring, transportation, provision or obtaining of a person for the purpose of a
commercial sex act.” (22 U.S.C. § 7102(9)).
3. Commercial sex act means “any sex act on account of which anything of value is given to or received by any person.” (22
U.S.C. § 7102(3)).
4. Coercion means threats of serious harm to or physical restraint against any person; any scheme, plan, or pattern intended
to cause a person to believe that failure to perform an act would result in serious harm to or physical restraint against any
person; or the abuse or threatened abuse of the legal process. (22 U.S.C. § 7102(2)).
5. Involuntary Servitude “includes a condition of servitude induced by means of (A) any scheme, plan, or pattern intended to
cause a person to believe that, if the person did not enter into or continue in such condition, that person or another
person would suffer serious harm or physical restraint; or (B) the abuse or threatened abuse of the legal process.” (22 U.S.
C. § 7102(5)).
6. Peonage means a status or condition of involuntary servitude based upon real or alleged indebtedness. (8 CRF 214.11).
7. Debt bondage means “the status or condition of a debtor arising from a pledge by the debtor of his or her personal
services or of those of a person under his or her control as a security for debt, if the value of those services as reasonably
assessed is not applied toward the liquidation of the debt or the length and nature of those services are not respectively
limited and defined.” (22 U.S.C. § 7102(4)).
The narrative may be typed below. If additional pages are required, please attach.

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Agency Verification and Consent to Information Sharing
for ORR Assistance to Child Trafficking Victims
Important guidance regarding information sharing.
ORR will use information collected in the Request for Assistance to determine a child's eligibility for
interim and long-term assistance (See 22 U.S.C. 7105(b)(1)(F)). Information gathered by ORR pursuant
to a Request for Assistance enables ORR to provide technical support to providers serving children
and, when appropriate, to facilitate placement of unaccompanied child trafficking victims into the
Unaccompanied Refugee Minors (URM) Program. ORR will make information available to non-HHS
entities only for the purposes described above and to comply with the TVPA.
If HHS provides interim assistance to a potential child trafficking victim, the TVPRA of
2008 requires HHS to notify the U.S. Departments of Justice (DOJ) and Homeland
Security (DHS) within 24 hours and to consult with DOJ, DHS, and nongovernmental
organizations with expertise on victims of trafficking prior to determining the child's
eligibility as a victim of trafficking. (See 22 U.S.C. 7105(b)(1)(F).) HHS routinely notifies
DOJ and DHS that children have been made eligible by HHS for assistance.
With the requestor's consent, ORR/ATIP will provide contact information for a requestor to DOJ and
DHS. If DOJ or DHS initiates an investigation or requests to speak with the child regarding the crime
of human trafficking, ORR encourages providers and law enforcement to coordinate with a child
advocacy center or similar model to facilitate the interview. A child is not required to cooperate
with law enforcement as a condition for receiving a letter of eligibility.
The information contained in this questionnaire may be disclosed for a legitimate law
enforcement purpose, including in response to a discovery request or otherwise in the
course of criminal or civil litigation. The requestor may want to assist the child in obtaining the
services of an attorney
Requestor consents to ORR sharing information with ORR-approved users. Requestor verifies that all
information provided is complete and accurate, to the best of his/her knowledge.

Requestor's Signature
Date

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