RDH-5 Request for Appeal of Risk Determination Hearing

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

Administration for Children & Families
Office of Refugee Resettlement

Request for Appeal of Risk
Determination Hearing
I appeal the decision by the hearing officer in the below-identified unaccompanied child’s Risk Determination Hearing, finding that the
child would present a danger to the community if released from ORR custody.
UC Name
DAB Docket No. U -

-

Date of Proceeding
1. I am the (check one, if applicable):
Unaccompanied child

Child’s Legal Representative (also include Form L-3) Child’s

Child’s Parent

Non-Accredited Representative

Child’s Legal Guardian
2. I understand I have 30 business days from the date of the hearing officer's written decision to submit this appeal request.
3. I understand I must attach the following to this request:
• A statement explaining the basis of this request (see below)
• Any additional relevant information I wish to be considered as part of the appeal. I further understand that the Office of the
Assistant Secretary at the Administration for Children and Families (Assistant Secretary) may subsequently contact me to
request clarification or further information.
4. I understand that once this request and associated materials are duly received, the Assistant Secretary will decide this case.
5. I understand the Assistant Secretary's decision concerning this appeal is the final administrative decision of the agency regarding
release of this child.
6. I understand the Assistant Secretary will send me acknowledgement of receipt of this request, copy ORR on the
acknowledgement, and request from ORR materials associated with the ORR Director's denial letter. I understand that if ORR
submits any new information, the Assistant Secretary will give me an opportunity to view the new information and respond as
appropriate.
7. Basis for Request
The child is not dangerous, and the decision of the Risk Determination Hearing officer should be reversed because:

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, the child’s parent, or the child’s representative to request an appeal of a Risk Determination hearing. 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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Request for Appeal of Risk Determination Hearing
Office of Refugee Resettlement

Signature
Name

Email Address

Relationship to Child
Date

Phone Number

UNACCOMPANIED CHILD CONTACT INFORMATION

Street Address
City

Email Address

REPRESENTATIVE CONTACT INFORMATION

Street Address
State

Zip Code

Phone Number

City

Email Address

State

Zip Code

Phone Number

Please submit this form directly to the Administration for Children and Families, Office of the Assistant Secretary at
[email protected].

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