Form 1 Collection Instrument

OMB Control No: 0970-NEW
Expiration date: xx/xx/xxxx

Dear Attorney,

We have received your contact information regarding the following victim’s T visa approval:

Initials: XXX             DOB: XX/XX/XXXX

Is this victim connected with a service provider who will assist them with applying for benefits?  If so, please provide their case manager’s email and phone number so we can move forward with the certification process.

If the victim does not yet have a service provider, please provide the following information so we can make a referral:

Client’s sex:  
Type of trafficking (sex, labor, both):
Language spoken:
Current city and state:  
Any emergency concerns:  

For more information on the benefits of HHS certification, please click here.

Best Regards,
Signature

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden of this collection of information is estimated to average .1 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to DHHS/ACF Reports Clearance Officer; 370 L’Enfant Promenade, S.W.; Washington, D.C. 20447