Welcome Corp Application - P4 Data

Welcome Corps Application (1405-0256)

Copy of Collection Instrument – P-4 Data Fields

The following refugee data fields will be collected and provided by private sponsor groups:

Biographical

Biographical Information

• Full Name

• First Name

• Middle Name

• Surname

• Second Surname

• Maiden Name

• Sex

• Head of Household (HoH)

• Relationship to Private Sponsorship Group (PSG)

• Relationship to HoH

• Marital Status

• Photo

Birth Information

• Birth Date

• Birth Country

• Birth State/Province

• Birth City

• Identifying Information

• Religion

• Ethnicity

• Nationality

Language

• Applicant

• Language

• Native Language

Current Address & Contact Information

• Current Address

• Applicant

• Current

• Country

• State/Province

• City

Current Contact Info

• Applicant

• Current

• Preferred

• Contact Type

• E-mail

• Phone Number
  
  
  

Proof of Refugee Registration

• Proof of Registration (POR) or Refugee Status Determination (RSD)

• POR or RSD Number

• POR or RSD Date
  
  
  

Comments/Additions/Explanations

Comments/Additions/Explanations

Refugee Status Information

• Previous or Pending USRAP Application

• Previous or Pending USRAP Application

• USRAP Case Number

• Principal Applicant (PA)

• Alien Registration Number (A-Number)
  
  
  

Pending SIV Application

Pending SIV Application

• KBL Number

• USRAP Case Number
  
  
  

Additional Information

• Permanent Immigration Status in any Third Country

• If yes, provide detail
  
  
  

Refugee Claim

Past Persecution

• Did the applicant previously suffer severe harm in his or her country of origin?

• Who was the perpetrator?

• What harm did the applicant experience?

• Was this on account of Race/Ethnicity, Religion, National Origin, Political Opinion, MPSG?

• If MPSG (Member of a Particular Social Group), specify what group

Well-Founded Fear of Future Persecution

• Is applicant afraid of being harmed if he or she returns to country of origin?

• Who does the applicant fear?

• What harm does the applicant fear?

• Would this be on account of Race/Ethnicity, Religion, National Origin, Political Opinion, MPSG?

• If MPSG (Member of a Particular Social Group), specify what group

Referrer Information

• Date of Form Completion

• Name of National Resettlement Agency

• Affiliate ID Number

• Private Sponsor Group (PSG)

• Private Sponsor Organization (PSO)

Signatures

U.S. Referrer (Family Member / Qualifying Parent or Legal Guardian / Private Sponsor)

• Signature

• Printed Name

• Date

Preparer/Interviewer

• Signature

• Printed Name

• Title

• Date

• Organization Name/Address

• Telephone Number

Interpreter

• Signature

• Printed Name

• Date

• Organization Name/Address

• Telephone Number

• Fax Number

• E-mail Address