Withdrawal of Application or Declination of Placement Form

Unaccompanied Refugee Minors Program Application, and Withdrawal of Application or Declination of Placement Form

Documents and Forms

Document Name Document Type
Form 1 Withdrawal of Application or Declination of Placement Form Form
1 Withdrawal of Application or Declination of Placement Fo Withdrawal of Application or Declination of Placement Form_CLEAN.docx Form
1 Withdrawal of Application or Declination of Placement Fo Withdrawal of Application or Declination of Placement Form_CLEAN.docx Form

Information Collection (IC) Details

IC Title:	Withdrawal of Application or Declination of Placement Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Withdrawal of Application or Declination of Placement Form	Withdrawal of Application or Declination of Placement Form_CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title: Refugee Arrivals Data System (RADS)	FR Citation: 87 FR 7178

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	50	20	30
Annual IC Time Burden (Hours)	10	4	6
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.