1 Withdrawal of Application or Declination of Placement Fo

O MB Control No: 0970-0550

Expiration date: XX/XX/XXXX

Withdrawal of Unaccompanied Refugee Minors (URM) Program Application

Instructions to Assister: Below is a statement the minor should sign if they would like to withdraw their application for the URM program. A withdrawal means that the minor is no longer interested in entering the URM program. Please provide the minor with assistance in completing the below statement. Please use an interpreter, if necessary.

Information to be filled in by assister:

Today’s Date:__________________

Minor’s Full Name: ______________________________________

Minor’s A# or HHS Tracking Number: _______________________

Assister’s Full Name: ____________________________________

Statement to be completed by minor, with assistance from assister and interpreter (if needed):

My name is ___________________________________. My application for the Unaccompanied Refugee Minors (URM) program was submitted on _______________(DATE). The URM program was explained to me by ______________________(NAME) on _________________(DATE) in _________________ (LANGUAGE). I understand the program, its services, and my potential rights and responsibilities. I choose to withdraw my application to the URM program. I understand I may not be able to enter the program at a later date.

_________________________________ __________________________________

Minor’s signature Assister’s signature

If interpreter was used, interpreter please complete the following:

I read this withdrawal statement to the minor listed above on _____________ (DATE). The minor stated that they understood the form and the consequences of withdrawing their URM application at this time.

Interpreter’s signature:______________________________________

Declination of Unaccompanied Refugee Minors (URM) Program Placement

Instructions to Assister: Below is a statement the minor should sign if they would like to decline a URM placement that was offered to them. A declination means that the minor is still interested in entering the URM program but would not like to go to the placement that was identified for them. Please provide the minor with assistance in completing the below statement. Please use an interpreter, if necessary.

Information to be filled in by assister:

Today’s Date:__________________

Minor’s Full Name: ______________________________________

Minor’s A# or HHS Tracking Number: _______________________

Assister’s Full Name: ____________________________________

Statement to be completed by minor, with assistance from assister and interpreter (if needed):

My name is ___________________________________. My application for the Unaccompanied Refugee Minors (URM) program was submitted on __________________(DATE). A placement in the URM program was found for me with _________________________(NAME OF AGENCY OFFERING PLACEMENT). I had a phone call with this URM program on _______________(DATE). I decline going to this URM placement. I would like ORR to try to find another placement for me. I understand that by declining this placement, ORR may not be able to find me another placement and I may not be able to enter the URM program at a later date.

_________________________________ __________________________________

Minor’s signature Assister’s signature

If interpreter was used, interpreter please complete the following:

I read this declination statement to the minor listed above on ____________ (DATE). The minor stated that they understood the form and the consequences of declining their URM placement at this time.

Interpreter’s signature:______________________________________

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide written notice that an unaccompanied minor is no longer interested in participating in the Unaccompanied Refugee Minors Program. Public reporting burden for this collection of information is estimated to average .20 hour per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0550 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Anne Mullooly in the Office of Refugee Resettlement at [email protected].