RDH-3 Appointment of Representative for Risk Determination Hea

OMB 0970-TBD [valid through MM/DD/YYYY]

Administration for Children & Families
Office of Refugee Resettlement

Appointment of Representative for Risk Determination Hearing
In the case of:
DAB Docket No. U -

-

As an unaccompanied child in the custody of the Office of Refugee Resettlement (ORR), you may have requested or been automatically
enrolled in a hearing before an independent hearing officer with United States Department of Health and Human Services. 45 C.F.R.
§ 410.1903. The purpose of this hearing is to determine whether or not you present a risk of danger to the community if you are released.
Information about Risk Determination Hearing procedure may be found in 45 CFR § 410.1903, in UC Policy Guide [Link TBD], and is available
upon request. You may be represented by a person of your choosing at this hearing. The representative is not required to be a licensed
attorney. You may appoint your representative by submitting this optional form to the child’s care provider Case Manager or directly to
ORR via [email protected].
The appointment must be signed by the appointed representative and either the child or his/her parent or legal guardian.
By appointing a representative, you authorize the representative to act on your behalf in this proceeding. The representative's authority
includes, but is not limited to, the authority to obtain information in connection to your hearing, make requests, present evidence, and to file
and accept service of all case-related documents. Additionally, you consent that your personal information related to this case may be
disclosed to the representative in the course of his/her representation. You may revoke this appointment at any time.

I certify that I am the parent or legal guardian of the unaccompanied child named above. I will act on the child’s behalf in this proceeding.

Street Address
Child’s Parent/Legal Guardian Signature
Child’s Parent/Legal Guardian Name

Date

City

Email Address

State

Zip Code

Phone Number

I certify that I am the unaccompanied child named above or the parent or legal guardian of the child. I appoint the representative listed
below to act on the child’s behalf in this proceeding.

Child/Parent/Legal Guardian Signature
Child/Parent/Legal Guardian Name

Representative's Signature
Date

Representative's Name

Date

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow an unaccompanied child or
the child’s parent/legal guardian may use this instrument to appoint a representative to act on the child’s behalf throughout the Risk Determination hearing process and
consent to the release of any unaccompanied child records that are related to the case to that representative. Public reporting burden for this collection of information is
estimated to average 0.17 hours per response, including the time for reviewing instructions, gathering, and maintaining the data needed, and reviewing the collection of
information. This is a mandatory collection of information (45 C.F.R. § 410.1903). 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. If you have any comments on this
collection of information, please contact [email protected].

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Appointment of Representative for Risk Determination Hearing
Office of Refugee Resettlement

Representative's Contact Information

Street Address
City

Email Address
State

Zip Code

Phone Number

I wish to revoke ability of the representative listed below to continue acting on my behalf in this proceeding.

Representative's Name
Child/Parent/Legal Guardian Signature
Child/Parent/Legal Guardian Name

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Date

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