Form 1 Discharge Notification

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average .24/hour 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.
OMB Control No: 0970-XXXX; Expiration date: XX/XX/XXXX

UC Basic Information
First Name:
Last Name:

AKA:
Status:
Date of Birth:
A No.:
Age:
Country of Birth:

Gender:
LOS:
Current Program:
Admitted Date:
Discharge Notification

Date of Discharge:
Type Of Discharge:

Transfer

Sponsor DOB:

Time of Discharge:
Sponsor Name:
Relationship to UC:

Prove of Relationship:
ORR Decision:

Pending

Date of Decision:

Approve
Disapprove
Remanded, please provide info as detailed in
comments

Program Minor was Transferred to:

DHS Family Shelter:

Local Law Enforcement:
Specify, if Other is Selected:
Address:
City:
State:

Zip Code:

Phone:

Fax:

Legal Status of Minor: