U. S. Repatriation Program Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Temporary Assistance Extension Request Form	Form and Instruction	New	Available
Form 1 State Request for Federal Support Form	Form and Instruction	New	Available
Form 1 Loan Waiver and Deferral Request	Form and Instruction	New	Available
Form 1 Non-emergency Monthly Financial Statement Form	Form and Instruction	New	Available
Form 1 Emergency Repatriation Financial Form	Form and Instruction	New	Available
Form 1 Refusal of Temporary Assistance Form	Form and Instruction	New	Available
Form 1 Privacy and Repayment Agreement Form	Form and Instruction	New	Available
Form 1 Emergency and Group Processing Form	Form and Instruction	New	Available
Repatriation Program and Supporting Statement OMB.doc	Supporting Statement A	Uploaded 2016-02-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
218660	Temporary Assistance Extension Request Form	Form and Instruction	New	Temporary Assistance Extension Request Form
218659	State Request for Federal Support	Form and Instruction	New	State Request for Federal Support Form
218658	Loan Waiver and Deferral Request Form	Form and Instruction	New	Loan Waiver and Deferral Request
218657	Non-emergency Monthly Financial Statement Form	Form and Instruction	New	Non-emergency Monthly Financial Statement Form
218656	Emergency and Group Repatriation	Form and Instruction	New	Emergency Repatriation Financial Form
218655	Refusal of Temporary Assistance	Form and Instruction	New	Refusal of Temporary Assistance Form
218654	Privacy and Repayment Agreement	Form and Instruction	New	Privacy and Repayment Agreement Form
218653	Emergency and Group Processing	Form and Instruction	New	Emergency and Group Processing Form

ICR Details

OMB Control No: 0970-0474	ICR Reference No: 201510-0970-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: U. S. Repatriation Program Forms
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/04/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/18/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	36 Months From Approved
Responses	51,524	0	0
Time Burden (Hours)	9,204	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This information is being requested in order to carry out the functions of the U.S. Repatriation Program. This program is authorized by Section 1113 of the Social Security Act (42 U.S.C. § 1313) and the assistance provided to mentally ill repatriates found under 24 U.S.C. §§ 321 - 329. This program also provides services under emergency and group repatriations which are authorized under Section 1113 and by the extension of the Executive Order (E.O.) precedent, E.O. 12656 (53 CFR 47491). General program regulations are found under 45 CFR 211 & 212. Under each requirement, specific information must be provided in order to determine eligibility, provide services, and properly manage the financial activities of this Program which includes collection of the amount associated to the services provided. In general, the U.S. Repatriation Program (hereinafter Program) was established in 1935 under Section 1113 (Assistance for U.S. Citizens Returned from Foreign Countries), to provide temporary assistance to U.S. citizens and their dependents identified by the Department of State as having returned, or been brought from a foreign country to the U.S. because of destitution, illness, war, threat of war, or a similar crisis, and are without available resources. Upon arrival in the U.S., services for repatriates are the responsibility of the Secretary of Health and Human Services. The Secretary has delegated these responsibilities to the Administration for Children and Families (ACF), and later was delegated from ACF to the Office of Refugee Resettlement (ORR). Temporary assistance, which is defined as cash payment, medical care (including counseling), temporary billeting (e.g., shelter), transportation, and other goods and services necessary for the health or welfare of individuals is given to eligible repatriates in the form of a service loan and must be repaid to the U.S. Government. Temporary assistance is available to repatriates for up-to 90-days and might be extended by ORR if the circumstances involved necessitate or justify the furnishing of such extension of services (42 U.S.C. § 1313). A case can be closed prior to reaching the 90th day upon finding that the eligible individual has resources available to meet his/her immediate needs. Once a case is closed, ORR through its arrangements with the Program Support Center begins collection of the amount associated to the services provided. Repatriates can apply for a waiver or deferral of their repatriation loan which is approved on a case by case basis by ORR (45 CFR 212).

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 34161	06/15/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 63226	10/19/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Emergency and Group Processing	1	Emergency and Group Processing Form
Emergency and Group Repatriation	1	Emergency Repatriation Financial Form
Loan Waiver and Deferral Request Form	1	Loan Waiver and Deferral Request
Non-emergency Monthly Financial Statement Form	1	Non-emergency Monthly Financial Statement Form
Privacy and Repayment Agreement	1	Privacy and Repayment Agreement Form
Refusal of Temporary Assistance	1	Refusal of Temporary Assistance Form
State Request for Federal Support	1	State Request for Federal Support Form
Temporary Assistance Extension Request Form	1	Temporary Assistance Extension Request Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	51,524	0	0	51,524	0	0
Annual Time Burden (Hours)	9,204	0	0	9,204	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR.

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Annual Cost to Federal Government: $794,858

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/18/2015

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