Form 1 State Request for Federal Support Form

U. S. Repatriation Program Forms

HHS Repatriation Program - State Request for Federal Support Form

State Request for Federal Support

OMB: 0970-0474

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OMB Control No: 0970-xxxx

Expiration date: xx/xx/xxxx

DEPARTMENT OF HEALTH & HUMAN SERVICES

ADMINISTRATION FOR CHILDREN AND FAMILIES

370 L’Enfant Promenade, S.W., Washington, D.C. 20447


U.S. REPATRIATION PROGRAM

Emergency and Group Repatriation

State Request for Federal Support Form

( NOTE: Use additional pages where space on this form is insufficient or continue on reverse side)

instruction: This form is to be completed by an official authorized by the State to request support from a Federal agency

(1) Requestor Name and Title

(2) State


(3) Date and Time Submitted


 

Date

Time



Type of Assistance Requested and Description: Attach supportive document or justification as needed









Requestor

E-mail:


Location Where Service/Support is Needed

Requestor Telephone:



Requestor Signature Date:


To be Completed by ACF authorized staff

This request is to be reviewed by the Financial Officer and approved by ACF authorized Official


ACF Financial Officer Name (print):_________________________________________ Sign:__________________________________________


Date/Time request was received from the State ______\_______\___________ Time ____________________


Federal AGENCY/INDIVIDUAL ASSIGNED TO EXECUTE THIS REQUEST

Date assigned


name of federal POINT OF contact (poc)


poc title


Poc telephone


poc e-mail


Authorized ACF Official


ACF Official Signature




Date




THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average 0.15 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.


Personal information provided on this form may only be disclosed for program purposes or under the conditions prescribe in 45 CFR 211.14 or 212.9.

File Typeapplication/msword
AuthorElizabeth Russell
Last Modified ByWindows User
File Modified2015-11-10
File Created2015-02-03

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