Form 1 Privacy and Repayment Agreement 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

Privacy and Repayment Agreement Form

Check this box if you are completing and signing this form on behalf of the repatriate. Please know that the repatriate must sign this form unless he is a minor or an adult with a physical or mental condition that prevents him/her from signing this form. You must be an authorized representative in order to sign on behalf of the repatriate. Print the below information if you are signing on behalf of the repatriate:

Representative Name: Relationship: Phone:

Note: Providing 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.

Privacy Act Statement

I, (print repatriate’s name)____________________________________________, authorize the Department of Health and Human Services (HHS), U.S. Repatriation Program (Program), to collect and have access to my protected health information (PHI) and to disclose my PHI to other Federal, State or private organizations, if necessary to enable the HHS to carry out its responsibilities under 42 U.S.C. 1313 and 24 U.S.C. Sections 321 through 329, or to enable another Federal agency to carry out any functions related to my return from a foreign country and entry into the United States, or as otherwise expressly authorized by appropriate HHS staff.

Acceptance of Repatriation Services and Repayment Agreement

I understand that all financial, medical, transportation and other temporary assistance provided to me through the Program must be repaid, unless a waiver is granted by authorized HHS officer. I understand that I will be billed by the HHS directly or through its designee for the cost of this aid, and I agree to repay this amount in full. Repayment in full or my first installment payment is due 30 days after billing. If I pay by installment, or am delinquent in repayment, interest at the current rate fixed by the U.S. Secretary of Treasury for private consumer loans will accrue on the unpaid portion. Until I repay in full the aid received, I agree to report all changes in my address to HHS at 330 C Street S.W., Washington D.C. 20201, Attention: U.S. Repatriation Program.

Repatriate’s Name (print) Last __________________________________ First/MI____________________________________

Address:______________________________________________________________________________________________

Street City State Zip Code

Repatriate Social Security Number: Phone Number:

I understand and agree to all terms and conditions of the Privacy Act Statement and the Repayment Agreement, and certify that the information provided above is correct. All payments must be sent to HHS- Program Support Center, Accounting Services – Debt Collection Center, 7700 Wisconsin Avenue, Suite 8-8110D, Mail Stop 1023B,

Bethesda, Maryland 20857 (Zip Code 20814 for UPS/FEDEX Mail). Email: [email protected] Telephone: 301-492-4664

.

Signature:

Date:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average 0.05 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.

Title 18 of the United States Code 1001 states that an individual who “knowingly and willfully - (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”

Form RR - 05