Form 1 Emergency and Group Processing Form

O MB Control No: 0970-0474

Expiration date: 03/31/2019

DEPARTMENT OF HEALTH & HUMAN SERVICES

ADMINISTRATION FOR CHILDREN AND FAMILIES

330 C Street S.W., Washington D.C. 20201

U.S. REPATRIATION PROGRAM

Emergency and Group Processing Form

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

Instructions: Please complete ONE FORM per individual or nuclear family. Include extra pages if space is not sufficient to provide the requested information. Please WRITE the applicant’s name on the right hand corner of each additional page. This form should be returned to the above address or electronically as instructed by the authorized Federal staff.

Intake Staff: before distributing this form, intake staff should verify that the signatory level of literacy and language skills are sufficient to allow comprehension of this form contents. In addition, minors should not be asked to complete this form. Instead, the minor’s representative (parent, guardian, or legal representative) may ordinarily sign on his/her behalf. Persons with mental and physical conditions that may impede their understanding and/or completion of this form should not be required to sign it. Representative (spouse, guardian, and/or legal representative) may ordinarily sign on his/her behalf.

1. Who is eligible? Applicants for temporary assistance must be U.S. citizens or dependents of U.S. citizens who have been returned or brought back to the U.S. due to a Department of State’s ordered or authorized evacuation from overseas because of war, threat of war, or similar crisis, and the person does not have resources immediately available to meet their needs. In addition, U.S. nationals may be eligible under 24 U.S.C. Sections 321 through 329.

2. Who should complete this form? Physical presence of individuals requesting HHS Repatriation temporary assistance is ordinarily required at the time of application. Limited exceptions may apply. For further information and guidance on these limitations please consult with the designated Administration for Children and Families (ACF) staff. Intake staff at the U.S Emergency Repatriation Center (ERC) can assist with the completion of this form. Below is a list of who can sign this form:

• Only those who fall within the above question 1

• Adults applying for themselves

• Adults applying on behalf of themselves and dependents

• Adult representative of a minor child (parent, guardian, or legal representative)

• Adult representative of a mentally or physically impaired adult

3. Disclaimer: Eligibility determinations are made by authorized staff from the ACF in the Department of Health and Human Services (HHS), in accordance to 45 CFR 211 and 212. The statutory authority for this collection is 42 U.S.C. Sections 1313, 24 U.S.C. Sections 321 through 329, and the Health Insurance Portability and Accountability Act of 1996. Information solicited on this repatriation form is for the purpose of determining your eligibility for temporary assistance under the Program. Furnishing the information on this form, including but not limited to the social security number, is voluntary. However, if you fail to provide the requested information, you may be found ineligible for repatriation assistance.

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

Title 18 of the United States Code 1001 states that an individual who “knowingly and wilfully - (1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; (2) makes any materially false, fictitious, or fraudulent statement or representation; or (3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry; shall be fined under this title, imprisoned not more than 5 years…or both”

The Paperwork Reduction Act of 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average 0.30 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.

P ART I: GENERAL INFORMATION: Check the box if you do not need repatriation services (please go to Part VII and sign this form)

1. Is the person requesting assistance a U.S. citizen or dependent? Yes No (speak with an ERC staff before continuing with this form)

2. I s the U.S. citizen or dependent 18 years or older? Yes No (go to Part II)

3. Name (Repatriate: First, Middle, Last)	4. Birth Date (MM/DD/YYYY)
5 . Address in the U.S.A (Street –City–State–Zip) Is this address permanent or temporary?	6. Sex M F
7. Place of Birth (Country/State)	8. U.S. Passport #
9. Phone/e-mail:	10. State of final destination
11. Repatriation Center (Airport/State)	12. Repatriated from (Country)

13. Accompanying Dependents: Please complete this information for each dependent. Write on the back of this form if you need to include more than five (5) dependents. After completing this information, go to Part III.

Name (First, Middle, Last)	Social Security Number	DOB (DD/MM/YYYY)	Passport #	Relationship to Repatriate
1
2
3
4
5

PART II: unaccompanied and accompanied minors: unless minors are related, one form must be used per child.

1. Are you completing this form on behalf of a minor U.S. citizen, under the age of 18 years?

Yes (go to question 3) No

2. Are you completing this form on behalf of a minor who (1) is the depended of a U.S. citizens, (2) is not a U.S. citizen, and (3) is under the age of 18 years?

Yes No

3. Write on the back of this form if you need to include more than three (3) children. If you are a Child Protective Service (CPS) staff completing this form on behalf of a minor, please write CPS under the question “Your relationship to the minor.”

child #1

Name (Minor: First, Middle, Last)							Birth Date (MM/DD/YYYY)
Home Address (Street – City – State – Zip)							Sex M F
Place of Birth (Country/State)							Social Security #
U.S. Passport #	State of final destination			Nationality				Repatriated from (Country)
Repatriation Center (Airport/State)			Phone/e-mail:
Is the child traveling unaccompanied? Yes No		Are you the legal guardian? Yes No				Your relationship to the minor
Name of legal guardian (First, Middle, Last)					Legal guardian telephone/s
Address of legal guardian (if different than above) (Street – City – State – Zip)					Legal guardian e-mail
Comments

child #2

Name (Minor: First, Middle, Last)							Birth Date (MM/DD/YYYY)
Home Address (Street – City – State – Zip)							Sex M F
Place of Birth (Country/State)							Social Security #
U.S. Passport #	State of final destination			Nationality				Repatriated from (Country)
Repatriation Center (Airport/State)			Phone/e-mail:
Is the child traveling unaccompanied? Yes No		Are you the legal guardian? Yes No				Your relationship to the minor
Name of legal guardian (First, Middle, Last)					Legal guardian telephone/s
Address of legal guardian (if different than above) (Street – City – State – Zip)					Legal guardian e-mail
Comments

child #3

Name (Minor: First, Middle, Last)							Birth Date (MM/DD/YYYY)
Home Address (Street – City – State – Zip)							Sex M F
Place of Birth (Country/State)							Social Security #
U.S. Passport #	State of final destination			Nationality				Repatriated from (Country)
Repatriation Center (Airport/State)			Phone/e-mail:
Is the child traveling unaccompanied? Yes No		Are you the legal guardian? Yes No				Your relationship to the minor
Name of legal guardian (First, Middle, Last)					Legal guardian telephone/s
Address of legal guardian (if different than above) (Street – City – State – Zip)					Legal guardian e-mail
Comments

PART III: Next of Kin or Emergency Contact in U.S.

Name	Tel/E-mail	Relationship to Repatriate
Name	Tel/E-mail	Relationship to Repatriate
Name	Tel/E-mail	Relationship to Repatriate
Name	Tel/E-mail	Relationship to Repatriate

PART IV: Eligibility Determination: To be Completed by the Intake Staff

Follow these instructions: If the evacuee is a U.S. national from one of the U.S. territories, please contact the ACF staff on site for assistance with the case. If the evacuee is not a U.S. citizen or dependent of a U.S. citizen please advise the person that he/she is not eligible for repatriation assistance. Explain that he/she will be able to obtain some of the services available at the ERC. If the evacuee is a U.S. citizen, or dependent of a U.S. citizen, please ask the following questions:			Y	N
Do you have resources (e.g. funds, transportation) immediately available to meet your needs while en route to your final destination?
Are any of your relatives, next of kin, friends, other individuals and/or association able to assist you with resources to meet your needs?
Do you need Repatriation Temporary Assistance? If yes, explain the repatriation loan and obtain signature on the HHS Repayment Agreement Form.
Would you need assistance at your state of final destination? If yes, explain, how the repatriation loan works and make sure to refer this repatriate to the appropriate ERC staff. Repatriates should be advised of the repatriation loan waiver and/or deferral process.
Intake Recommended Services: please check those that apply
Transportation		Lodging
Medical		Cash Advance
Other (specify)		Referral to state of final destination
Based on the guidance provided, is a special referral needed? Specify
Check point: Before obtaining signature from the Federal Official, make sure the following has been done:			Y	N
Welcome package, and all necessary forms, (e.g. Repayment Agreement Form) were provided and explained.
Copy of the U.S. passport (biographical information only), or other proof of U.S. citizenship is attached to this form.
Repatriate was provided with information on the how to apply for a waiver and/or deferral of their loan.
If applicable, repatriate has been given information regarding repatriation assistance at state of final destination (SFD).
Ensure all forms, including this document, have been signed.
After the Federal Official signs this form, refer repatriate to the appropriate service table/location.

Federal Approving Official/Agency: Approved Denied

Date

Comments:

PART V: Repatriation Services: Below is to be completed by the staff who is providing and/or coordinating the services.

Individual providing assistance should initial the appropriate service category line and where applicable indicate the amount associated to the service provided. Once all necessary services have been given to the repatriate, keep the original and if necessary, provide a copy to the repatriate.

Lodging ___________ Medical____________

Staff initials Staff initials

T otal $ ______________ Transported to Hospital? ______________

Total nights:__________ Received services at the ERC? Y N

Cash Advance _____________ $ ____________

Staff initials

Transportation/Travel: ___________ Total $_____________ This amount may or may not include fees. Attach to this form a copy of each travel

Staff initials itinerary and/or copy of transportation contract arrangement.

Other (specify): for escort services, type the full name, contact information, and other applicable escort’s information.

Referral to state of final destination done by:

Date:

State:

Contact at State of Final Destination (name/telephone/email):

PART VI: Interpreter

1. W as an interpreter utilized? Yes No

2. Interpreter’s name: _________________________________________

Part VII: Signature

The head of the family should sign this form. For repatriates who are18 or younger, the legal guardian or responsible person should sign on their behalf. If guardian or responsible person is not present, case may be treated as an unaccompanied minor and referred to CPS for assistance. For repatriates who are not able to sign this form due to medical or developmental conditions, and do not have a legal guardian or responsible person assisting, the intake person should write a note advising on the situation (e.g. person incapacitated). A referral might be necessary to Adult Protective Services (APS).

Signature

Print Name

Date

Intake person’s NOTES:

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