Form S-5 Sponsor Assessment

OMB 0970-0XXX Valid Through MM/DD/YYYY

Administration for Children and Families

Office of Refugee Resettlement

Sponsor Assessment (Form S-5)

UAC Portal Version

UAC Sponsor Information

UAC Basic Information

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow case managers to document their assessment of the suitability of a potential sponsor to provide for the safety and wellbeing of an unaccompanied alien child. Public reporting burden for this collection of information is estimated to average 1.0 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 (Homeland Security Act, 6 U.S.C. 279, and Trafficking Victims Protection Reauthorization Act, 8 U.S.C. 1232). 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].

First Name	AUTO POPULATE	AKA	AUTO POPULATE
Last Name	AUTP POPULATE	Status:	AUTO POPULATE
Date of Birth:	AUTO POPULATE (MM/DD/YYYY)	Admitted Date:	AUTO POPULATE
Age:	SYSTEM GENERATED	LOS:	SYSTEM GENERATED
A No.:	AUTO POPULATE	Current Program:	AUTO POPULATE
Country of Birth:	AUTO POPULATED	Portal ID:	AUTO POPULATE
Sex:	AUTO POPULATE < Male, Female,>	Current Location of the Child:	AUTO POPULATE (Data Source: UAC Discharge Tab)

Sponsor Assessment

Current Sponsor Status:

<Dropdown Menu> (-Select One- Pending Contact; Successfully Contacted; Confirmed Interest; Declined Sponsorship; FRA Complete; Undergoing Vetting; Found Suitable; Approved; Disqualified; Other)

Sponsor Demographic Information Tab

Sponsor Demographic Information

This is a unique sponsor profile. If you identify a different sponsor for the child, search for that sponsor and assign them. If they don’t exist in Portal, add a new sponsor profile. Do not overwrite the fields below with information about another sponsor.

Form Started: SYSTEM GENERATED (MM/DD/YYYY at HH:MM AM/PM ET)

Sponsor Demographic Information tab last updated by AUTO POPULATE (NAME OF CASE MANAGER/ UNIFICATION SPECIALIST) on SYSTEM GENERATED (MM/DD/YYYY at HH:MM AM/PM ET)

Basic Information

Sponsor Identification Number

SYSTEM GENERATED

First Name*

(OPEN TEXT)

Last Name*

(OPEN TEXT)

Date of Birth*

(OPEN TEXT MM/DD/YYYY)

Country of Birth*

<Dropdown Menu> (- Select a country - All Countries)

A#

(OPEN TEXT)

Sex:

c Male c Female

Date Sponsor Identified:

<POP UP CALENDAR>

Phone & Email

Primary Phone #*

(OPEN TEXT)

Backup Phone #*

(OPEN TEXT)

Backup Phone Type

<Dropdown Menu> (-Select Backup Phone Type - ACG/Friend/Family; Home; Mobile; Work; Other)

Email Address

(OPEN TEXT)

Proof of Identity
Has the sponsor identity been verified?		c Yes c No
Documents establishing proof of identity
Document type		Expiration Date	Verified by Government Agency	Picture ID	Options
<Dropdown Menu> (-Choose an item – US Passport or US Passport Card;; Permanent Resident Card or Alien Registration Receipt Card (I-551); Foreign passport with temporary I-551 stamp; Copy of temporary I-551 notation on machine-readable immigrant visa; Employment Authorization Document with photo (I-766); Foreign passport with Form I-94; Foreign passport with Form I-94A with Arrival-Departure Record & endorsement to work; Passport from the Federated States of Micronesia (FSM) with form I-94 or I-94A; Passport from the Republic of the Marshall Islands (RMI) with form I-94 or I-94A; U.S. Driver’s License or identification card with photo or Name, DOB, Gender, Height, Eye Color, and Address; ID card issued by U.S. federal, state, or local government agencies or entities, with photo or Name, DOB, Gender, Height, Eye Color, and Address;; U.S. Military Identification Card; U.S. Military dependent’s ID card; U.S. Coast Guard Merchant Mariner Card; Native American tribal document; Driver’s License issued by a Canadian government authority; Category 1 Sponsor Only: Other Government-issued photo identity document and seeking exception from ORR under UAC Policy Guide Section 2.2.4, specify below;)		<POP UP CALENDAR>	c Yes c No	c Yes c No	SAVE
Document any additional information relevant to the sponsor’s identity.		(OPEN TEXT)
Language & Religion
Preferred Language	(OPEN TEXT)
Other Language	(OPEN TEXT)
Religious Affiliation (if any)	(OPEN TEXT)
Additional Information
Document any additional information relevant to the sponsor's identity, legal status, and linguistic and cultural background.	(OPEN TEXT)
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Contact Information Tab

Contact Information
Contact Information tab last updated by AUTO POPULATE (NAME OF CASE MANAGER/ UNIFICATION SPECIALIST) on SYSTEM GENERATED (MM/DD/YYYY at HH:MM AM/PM ET)
Current Address
Search for an Address	(OPEN TEXT) HELPTEXT: Search for an Address
	Address wasn’t found in search bar? (Unlocks editable address fields below)
Address Line 1*	(OPEN TEXT) HELPTEXT: 123 Main St.
Address Line 2	(OPEN TEXT) HELPTEXT: (e.g. Apt. 4)
City*	(OPEN TEXT)
State*	<Dropdown Menu> (-Select State- Alabama; Alaska; Arizona; Arkansas; American Samoa; California; Colorado; Connecticut; Delaware; District of Columbia; Florida; Georgia; Guam; Hawaii; Idaho; Illinois; Indiana; Iowa; Kansas; Kentucky; Louisiana; Maine; Maryland; Massachusetts; Michigan; Minnesota; Mississippi; Missouri; Montana; Nebraska; Nevada; New Hampshire; New Jersey; New Mexico; New York; North Carolina; North Dakota; Northern Mariana Islands; Ohio; Oklahoma; Oregon; Pennsylvania; Puerto Rico; Rhode Island; South Carolina; South Dakota; Tennessee; Texas; Trust Territories; Utah; Vermont; Virginia; U.S. Virgin Islands; Washington; West Virginia; Wisconsin; Wyoming)
Zip Code*	(OPEN TEXT)
Country*	<Dropdown Menu> (-Select Country- Afghanistan; Aland Islands; Albania; Algeria; American Samoa; Andorra; Angola; Anguilla; Antarctica; Antigua and Barbuda; Arabian Peninsula; Argentina; Armenia; Aruba; Australia; Austria; Azerbaijan; Bahamas; Bahrain; Bangladesh; Barbados; Belarus; Belgium; Belize; Benin; Bermuda; Bhutan; Bolivia; Bonaire, Sint Eustatius and Saba; Bosnia and Herzegovina; Botswana; Bouvet Island; Brazil; British Virgin Islands; Brunei; Bulgaria; Burkina Faso; Burundi; Cambodia; Cameroon; Canada; Cape Verde; Cayman Islands; Central African Republic; Chad; Chile; China; Chinese Taipei; Christmas Island; Cocos Islands; Colombia; Comoro Islands; Congo; Cook Islands; Costa Rica; Cote D'Ivoire; Croatia; Cuba; Curaçao; Cyprus; Czech Republic; Czechoslovakia; Dem Rep Of The Congo; Denmark; Djibouti; Dominica; Dominican Republic; East Timor; Ecuador; Egypt; El Salvador; Equatorial Guinea; Eritrea; Estonia; Ethiopia; Falkland Islands; Faroe Islands; Fiji; Finland; France; French Guiana; French Polynesia; French Southern And Antarctic; Gabon; Gambia; Georgia; Germany; Ghana; Gibraltar; Greece; Greenland; Grenada; Guadeloupe; Guam; Guatemala; Guernsey; Guinea; Guinea-Bissau; Guyana; Haiti; Heard Island and McDonald Islands; Holy See; Honduras; Hong Kong; Hungary; Iceland; India; Indonesia; Iran; Iraq; Ireland; Isle of Man; Israel; Italy; Ivory Coast; Jamaica; Japan; Jersey; Jordan; Kazakhstan; Kenya; Kiribati; Korea; Kosovo; Kuwait; Kyrgyzstan; Laos; Latvia; Lebanon; Lesotho; Liberia; Libya; Liechtenstein; Lithuania; Luxembourg; Macao; Macedonia; Madagascar; Malawi; Malaysia; Maldives; Mali; Malta; Mariana Islands; Northern Maritime; Marshall Islands; Martinique; Mauritania; Mauritius; Mayotte; Mexico; Micronesia; Moldova; Monaco; Mongolia; Montenegro; Montserrat; Morocco; Mozambique; Myanmar; Namibia; Nauru; Nepal; Netherlands; Netherlands Antilles; New Caledonia; New Zealand; Nicaragua; Niger; Nigeria; Niue; Norfolk Island; North Korea; Norway; Oman; Pakistan; Palau; Palestinian Territory, Occupied; Panama; Papua New Guinea; Paraguay; Peru; Philippines; Pitcairn Islands; Poland; Portugal; Puerto Rico; Qatar; Reunion; Romania; Russia; Rwanda; ST. Pierre And Miquelon; Saint Barthelemy; Saint Kitts and Nevis; Saint Lucia; Saint Martin (French part); Saint Vincent And the Grenadines; Samoa; San Marino; Sao Tome and Principe; Saudi Arabia; Senegal; Serbia; Seychelles; Sierra Leone; Singapore; Sint Maarten (Dutch part); Slovakia; Slovenia; Solomon Islands; Somalia; South Africa; South Georgia and the South Sandwich Islands; South Korea; South Sudan; Spain; Sri Lanka; St. Helena; Sudan; Suriname; Svalbard and Jan Mayen; Swaziland; Sweden; Switzerland; Syria; Taiwan; Tajikistan; Tanzania; Thailand; Togo; Tokelau; Tonga; Trinidad and Tobago; Tunisia; Turkey; Turkmenistan; Turks And Caicos Islands; Tuvalu; USSR; Uganda; Ukraine; United Arab Emirates; United Kingdom; United States of America; Unknown; Uruguay; Uzbekistan; Vanuatu; Venezuela; Vietnam; Virgin Islands, U.S.; Wallis And Futuna Islands; West Bank; Western Sahara; Western Samoa; Yemen; Yugoslavia; Zambia; Zimbabwe)
How long has sponsor lived at their current address?	(OPEN TEXT)
Proof of Address
Was the sponsor’s current address verified as a residence on Google Maps?	c Yes c No
Was the sponsor’s current address verified as a residence on Google Earth?	c Yes c No
Was the sponsor’s current address verified as a residence on SmartyStreets?	c Yes c No
Documents Establishing Proof of Address

Document Type		Date Issued	Dated within 30 Days?	Options
<Dropdown Menu> (- Choose Item – Bank Statement issued <30 days prior; Current Lease Mail – Utility Bill addressed to sponsor & dated <30 days prior; Mail – Other; Mortgage Statement dated <30 days prior Official Payroll Check Stub issued by employer & dated <30 days prior; Valid un-expired State-issued Photo ID with address; )		<POP UP CALENDAR>	c Yes c No	SAVE
Additional Information
Document any additional information relevant to the sponsor's address, including your assessment of whether the sponsor lives at the address and whether that address is a residence.	(OPEN TEXT)
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Relationship to Child Tab

Relationship to Child
Relationship to Child tab last updated by AUTO POPULATE (NAME OF CASE MANAGER/ UNIFICATION SPECIALIST) on SYSTEM GENERATED (MM/DD/YYYY at HH:MM AM/PM ET)
Relationship to Child: AUTO POPULATE (NAME OF CHILD)
Sponsor’s Relationship to Child		<Dropdown Menu> ( -Select Relationship – Adult First Cousin ( non-primary caregiver); Adult First Cousin (Primary Caregiver); Adult Nephew (Primary Caregiver); Adult Nephew (Non-Primary Caregiver); Adult Niece (Primary Caregiver); Adult Niece (Non-Primary Caregiver); Aunt; Brother; Brother-in-law (Non-Primary Caregiver); Brother-in-Law (Primary Caregiver); Father; Godfather; Godmother; Grandfather; Grandmother; Half-sibling (Non-Primary Caregiver); Half-sibling (Primary Caregiver); Legal Guardian; Mother; Other Distant Relative; Sister; Sister-in-Law (Non-Primary Caregiver); Sister-in-Law (Primary Caregiver); Stepbrother; Stepfather (Legally Adopted); Stepfather Non-legally Adopted (Non-Primary Caregiver); Stepfather Non-Legally Adopted (Primary Caregiver); Stepmother legally Adopted; Stepmother Non-Legally Adopted (Non-Primary Caregiver); Stepmother Non-Legally Adopted (Primary Caregiver); Stepsister; UAC Spouse; Uncle (Non-Primary Caregiver); Uncle (Primary Caregiver); Unrelated Sponsor)
Sponsor Category		SYSTEM GENERATED
Primary Sponsor?		c Yes c No
How does the sponsor know the child or the child’s Family?		(OPEN TEXT)
Has the sponsor’s relationship to the child been verified?		c Yes c No
Was DNA used to establish proof of relationship?		c Yes c No
Proof of Relationship
Documents establishing proof of relationship:
Document Type	Expiration Date		Date Issued	Verified by Government Agency or Consulate	Comment	Options
<Dropdown Menu> ( - Choose an Item –; Birth Certificate - child; Birth Certificate – Sponsor; Birth Certificate – Other; Consulate Written Affirmation of Relationship; Court Order – Adoption; Court Order – Guardianship; Court Order – Other; Death Certificate; Category 3 Sponsor Family Session Case Note; Category 3 Sponsor – Other (specify); Marriage Certificate;)	<Pop Up Calendar>		<Pop Up Calendar>	c Yes c No	(OPEN TEXT)	SAVE
Knowledge of Child's Journey
According to the sponsor, why did the child leave their home country to come to the U.S.?		(OPEN TEXT)
Is the sponsor aware of any issues that the child experienced along the journey that may need to be addressed when the child comes to live with them?		c Yes c No
Does the sponsor owe any debt for the child's trip?		c Yes c No
Additional Information
Document any additional information relevant to the sponsor's familial and interpersonal relationship with the child, and the sponsor's role in coordinating or financing the child's journey to the U.S.		(OPEN TEXT)
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Criminal History & Background Checks Tab

Criminal History & Background Checks
Criminal History and Background Checks tab last updated by AUTO POPULATE (NAME OF CASE MANAGER/ UNIFICATION SPECIALIST) on SYSTEM GENERATED (MM/DD/YYYY at HH:MM AM/PM ET)
Self‐Disclosed Criminal History
Did the sponsor disclose any criminal history?		c Yes c No
Criminal Activity Disclosed by the Sponsor:		(OPEN TEXT)
Felony Convictions disclosed by the Sponsor:		(OPEN TEXT)
Misdemeanor convictions disclosed by the Sponsor:		(OPEN TEXT)
Probation/ Parole disclosed by the Sponsor:		(OPEN TEXT)
Legal issues related to substance use (e.g., D.U.I.: D.W.I.; Possession/ Manufacture/ Distribution of Controlled Substances)		(OPEN TEXT)
Domestic Violence disclosed by the Sponsor:		(OPEN TEXT)
History of Incarceration or detention:
Crime	Date		Length	Location	Options
(OPEN TEXT)	<POP UP CALENDAR>		(OPEN TEXT)	(OPEN TEXT)	SAVE

Document any additional information relevant to the sponsor's disclosure of criminal charges, sexual offenses, or child abuse/neglect charges or arrests.

If there are any disqualifying factors under the Criteria for Release Denial, identify those here. See ORR Policy Guide, Section 2.7.4 Deny Release Request for details.

(OPEN TEXT)

Background Checks
Background Check Details:
Background Check Type	Check Required in All Cases?	Check Requested?	Date Requested:	Date Results Received:	Results
Public Records	SYSTEM GENERATED BASED ON SPONSOR CATEGORY: YES/ NO	c	<POP UP CALENDAR>	<POP UP CALENDAR>	<Dropdown Menu> ( - Select Result – Clear; Not Clear)
Sex Abuse Registry	SYSTEM GENERATED BASED ON SPONSOR CATEGORY: YES/ NO	c	<POP UP CALENDAR>	<POP UP CALENDAR>	<Dropdown Menu> ( - Select Result – Clear; Not Clear)
FBI Criminal History	SYSTEM GENERATED BASED ON SPONSOR CATEGORY: YES/ NO	c	<POP UP CALENDAR>	<POP UP CALENDAR>	<Dropdown Menu> ( - Select Result – Appears Clear; Referred to FFS; Unclassifiable)
CA/N	SYSTEM GENERATED BASED ON SPONSOR CATEGORY: YES/ NO	c	<POP UP CALENDAR>	<POP UP CALENDAR>	<Dropdown Menu> ( - Select Result – Clear; Not Clear)
FBI Name Check		c	<POP UP CALENDAR>	<POP UP CALENDAR>	<Dropdown Menu> ( - Select Result – Appears Clear; Referred to FFS)
State/ Local		c	<POP UP CALENDAR>	<POP UP CALENDAR>	<Dropdown Menu> ( - Select Result – Clear; Not Clear)

Additional Information

Document any additional information relevant to background checks. Including whether the sponsor's self‐disclosure matches the background check results

(OPEN TEXT)

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Sponsorships Tab

Sponsorships

Sponsorships

Self-Reported Sponsorships

According to the sponsor, have they ever attempted to sponsor a child in ORR care?

c Yes c No

Self-Reported Sponsorships

Name

A#

DOB

Age

Sex

Relationship to Child

Current Location

ORR Release Decision

Date of Discharge

Discharge Program Name

Option

(OPEN TEXT)

(OPEN TEXT)

<Pop Up Calendar>

SYSTEM GENERATED

<Dropdown Menu> ( -Select One- Male; Female)

<Dropdown Menu> ( -Select Relationship – Adult First Cousin; Adult Nephew; Adult Niece; Aunt; Brother; Brother-in-law; Daughter; Daughter-in-Law; Family Friend; Father; First Cousin; Goddaughter; Godfather; Godmother; Godson; Granddaughter; Grandfather; Grandmother; Grandson; Half-sibling; Institutional/ Organizational Sponsor; Legal Guardian; Mother; Nephew; Niece; Other Cousin; Other Distant Relative; Parent’s Partner; Qualified Step Parents; Sister; Sister-in-Law; Son; Son-in-law; Sponsor’s Partner; Stepdaughter; Stepbrother; Stepfather; Stepmother; Stepson; Stepsister; child’s Spouse; Uncle; Unknown; Unrelated Sponsor)

<Dropdown Menu> ( - Chose an Item – Living with Sponsor; Not Living with Sponsor; Returned to Home Country)

<Dropdown Menu> ( - Chose an Item – Approve Straight Release; Approve with Post-Release Services Only; Deny Release; Approve with Post-Release Services)

<Pop Up Calendar>

(OPEN TEXT)

SAVE

Is the child still residing with them?

c Yes c No

If no, explain why the child is not residing with them:

(OPEN TEXT)

Did the sponsor undergo a home study for any of these sponsorships?

c Yes c No

Has the child received Post Release Services?

c Yes c No

Is the child enrolled in or attending school?

c Yes c No

When is the child's upcoming court date?

<POP UP CALENDAR>

Did the sponsor attend a Legal Orientation Program for Custodians (LOPC)?

c Yes c No

According to the sponsor, have they ever withdrawn an application to sponsor a child in ORR care?

c Yes c No

If yes, why did they withdraw?

(OPEN TEXT)

According to the sponsor, have they ever been denied sponsorship by ORR?

c Yes c No

If yes, why did ORR deny their sponsorship application?

(OPEN TEXT)

Sponsorships Recorded in Portal

Actual Sponsorships (A count) SYSTEM GENERATED

Potential Sponsorships (P count) SYSTEM GENERATED

Actual Sponsorship

Date

Primary

Child A#

Child Name

DOB

Age

Sex

COB

Relationship

Program

Status

Discharge Type

ORR Decision

Clearance

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

Potential Sponsorships

Date

Primary

Child A#

Child Name

DOB

Age

Sex

COB

Relationship

Program

Status

Discharge Type

ORR Decision

Clearance

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

Potential Sponsorships

Past Addresses

Addresses Recorded in Portal

Date Recorded

Street Address

City/State/Postal

Child Sponsored at Address

AUTO POPULATE (MM/DD/YYYY HH:MM:SS AM/PM)

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE (CHILD NAME; A#)

Other Sponsors Using Address

Other Sponsors Using Address

Name

Flags

Sponsorship Type

Date of Sponsor Assignment

Household Occupants

Address

Relationship to Child

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

AUTO POPULATE

Total Number of Other Sponsors Using Address: SYSTEM GENERATED

Additional Information

Document any additional information relevant to previous sponsorship attempts, including your assessment of the safety and well‐being of any children released from ORR care to the sponsor.

(OPEN TEXT)

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Family Relationships Tab

Family Relationships
Spouse ∕ Partner
Does the sponsor have a partner? If yes, enter the partner's information into the Family/Family Friend's table below.				c Yes c No
Is the sponsor legally married or is the relationship a partnership or cohabitation?				(OPEN TEXT)
Marriage status				<Dropdown Menu> (-Select- Married; Single)
Sponsor's Children
Does the sponsor have any children? If y				c Yes c No
Sponsor’s Children Details:
Name	DOB	Age	Sex		Current Location	Name of Mother/ Father	Options
(OPEN TEXT)	<Pop Up Calendar>	SYSTEM GENERATED	<Dropdown Menu> (-Select- Male; Female)		(OPEN TEXT)	(OPEN TEXT)	SAVE
Have any of the sponsor’s children ever been in ORR care?				c Yes c No
Who is caring for the sponsor’s children?				(OPEN TEXT)
How does the sponsor discipline their children?				(OPEN TEXT)
Does the sponsor provide court-ordered financial support to their children?				c Yes c No
Has the sponsor or their spouse/ partner ever interacted with Child Protective Services?				c Yes c No
If Yes, Explain:				(OPEN TEXT)
Has a child ever been removed from the sponsor’s custody?				c Yes c No
If Yes, provide documentation)
Has the sponsor ever been involved in a child support case?				c Yes c No
If Yes, explain:				(OPEN TEXT)

Family & Family Friends in U.S.
Does the sponsor have family or family friends in the U.S.?		c Yes c No
Family and Family Friends in the U.S.
Name	Age	Relationship to Sponsor	Options
(OPEN TEXT)	(OPEN TEXT)	<Dropdown Menu> ( -Select Relationship – Adult First Cousin; Adult Nephew; Adult Niece; Aunt; Brother; Brother-in-law; Daughter; Daughter-in-Law; Family Friend; Father; First Cousin; Goddaughter; Godfather; Godmother; Godson; Granddaughter; Grandfather; Grandmother; Grandson; Half-sibling; Institutional/ Organizational Sponsor; Legal Guardian; Mother; Nephew; Niece; Other Cousin; Other Distant Relative; Parent’s Partner; Qualified Step Parents; Sister; Sister-in-Law; Son; Son-in-law; Sponsor’s Partner; Stepdaughter; Stepbrother; Stepfather; Stepmother; Stepson; Stepsister; Child’s Spouse; Uncle; Unknown; Unrelated Sponsor)	SAVE
Does the sponsor have any relatives in ORR care?		c Yes c No
If yes, where are they?		(OPEN TEXT)
Family in Country of Origin
Does the sponsor have family in their home country?		c Yes c No
Describe the sponsor's relationship with their family in their home country.		(OPEN TEXT)
Additional Information
Document any additional information relevant to the sponsor's familial and other significant relationships in their country of origin and in the U.S.		(OPEN TEXT)
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Household Tab

Household

Housing Situation

Describe the sponsor’s home:

(OPEN TEXT)

Where will the child sleep:

(OPEN TEXT)

How does the sponsor expect the child to contribute to their household?

(OPEN TEXT)

Does the sponsor have adequate housing?

c Yes c No

Describe the sponsor’s housing conditions (Case Manager’s assessment)

(OPEN TEXT)

Household Members

Does anyone else live in the sponsor’s home?

c Yes c No

Household Members

First Name

Last Name

DOB

Sex

Age

Phone Number

Relationship to Sponsor

Dependent to Sponsor Income?

Background Checks

Options

(OPEN TEXT)

(OPEN TEXT)

<POP UP CALENDAR>

<Dropdown Menu> (-Select One- Male; Female)

SYSTEM GENERATED

(OPEN TEXT) (###-###-####)

<Dropdown Menu> ( -Select Relationship – Adult First Cousin; Adult Nephew; Adult Niece; Aunt; Brother; Brother-in-law; Daughter; Daughter-in-Law; Family Friend; Father; First Cousin; Goddaughter; Godfather; Godmother; Godson; Granddaughter; Grandfather; Grandmother; Grandson; Half-sibling; Institutional/ Organizational Sponsor; Legal Guardian; Mother; Nephew; Niece; Other Cousin; Other Distant Relative; Parent’s Partner; Qualified Step Parents; Sister; Sister-in-Law; Son; Son-in-law; Sponsor’s Partner; Stepdaughter; Stepbrother; Stepfather; Stepmother; Stepson; Stepsister; Child’s Spouse; Uncle; Unknown; Unrelated Sponsor)

c Yes c No c Partial

SYSTEM GENERATED

SAVE

Does anyone in the household have a serious contagious disease?

c Yes c No

If Yes, Explain:

(OPEN TEXT)

Does anyone in the household have criminal convictions or charges other than minor traffic violations?

c Yes c No

If Yes, Explain:

(OPEN TEXT)

Has anyone the sponsor lived with ever had a child removed from their custody?

c Yes c No

If Yes, Explain:

(OPEN TEXT)

Has anyone in the sponsor household attempted to sponsor a child in ORR care?

c Yes c No

Household Member Sponsorships

Name

A#

DOB

Sex

Sponsor’s Relationship to Child

Current Location

ORR Release Decision

Date of Discharge

Discharge Program Name

Options

(OPEN TEXT)

(OPEN TEXT)

<POP UP CALENDAR>

<Dropdown Menu> (-Select One- Male; Female)

<Dropdown Menu> ( -Select Relationship – Adult First Cousin; Adult Nephew; Adult Niece; Aunt; Brother; Brother-in-law; Daughter; Daughter-in-Law; Family Friend; Father; First Cousin; Goddaughter; Godfather; Godmother; Godson; Granddaughter; Grandfather; Grandmother; Grandson; Half-sibling; Institutional/ Organizational Sponsor; Legal Guardian; Mother; Nephew; Niece; Other Cousin; Other Distant Relative; Parent’s Partner; Qualified Step Parents; Sister; Sister-in-Law; Son; Son-in-law; Sponsor’s Partner; Stepdaughter; Stepbrother; Stepfather; Stepmother; Stepson; Stepsister; Child’s Spouse; Uncle; Unknown; Unrelated Sponsor)

<Dropdown Menu> ( - Chose an Item – Living with Sponsor; Not Living with Sponsor; Returned to Home Country)

<Dropdown Menu> ( - Chose an Item – Approve Straight Release; Approve with Post-Release Services Only; Deny Release; Approve with Post-Release Services)

<POP UP CALENDAR>

(OPEN TEXT)

SAVE

Is the child still residing with the household member?

c Yes c No

If No, explain why the child is not residing with them:

(OPEN TEXT)

Did the household member undergo a home study for any of these sponsorships?

c Yes c No

Has the child received Post-Release Services

c Yes c No

Is the child enrolled in or attending school?

c Yes c No

When is the child’s upcoming court date?

<POP UP CALENDAR>

Did the household member attend a Legal Orientation Program for Custodians (LOPC)?

c Yes c No

Has a household member ever withdrawn an application to sponsor a child in ORR care?

c Yes c No

If Yes, why did they withdraw?

(OPEN TEXT)

Has a household member ever been denied sponsorship by ORR?

c Yes c No

If Yes, why did ORR deny their sponsorship application?

(OPEN TEXT)

Proof of Identity for Household Members
Have all household members’ identities been verified?			c Yes c No
Documents establishing proof of household members identities:
Household Member Name	Document Type			Expiration Date	Verified by Government Agency	Picture ID?	Options
(OPEN TEXT)	<Dropdown Menu> ( - Choose an Item - U.S. Passport or U.S. Passport Card; Permanent Resident Card or Alien Registration Receipt Card (Form I-551) Foreign Passport with temporary I-551 Stamp; Foreign passport with temporary I-551 printed notation on machine-readable immigrant visa; Employment Authorization Document that contains a photograph (FormI-766) Foreign passport with Form I-94; Foreign passport with Form I-94A with Arrival-Departure Record & endorsement to work; Passport from the Federated States of Micronesia (FSM) with Form I-94 or I-94A; Passport from the Republic of the Marshall Islands (RMI) with Form I-94 or I-94A; Driver’s License or ID card issued by a U.S. state or outlying possession of the U.S. with photo or Name, DOB, Gender, Height, Eye Color, and Address; ID Card issued by U.S. federal, state, or local government agency or entity with photo or Name, DOB, Gender, Height, Eye Color, and Address; U.S. Military card; U.S. Draft Record; U.S. Military dependent’s ID card; U.S. Coast Guard Merchant Mariner Card; Native American tribal document; Driver’s license issued by Canadian government authority; Category 1 Sponsor Only – other government-issued photo ID and seeking exception from ORR under UAC Policy Guide Sec. 2.2.4) )			<POP UP CALENDAR>	c Yes c No	c Yes c No	SAVE
Additional Information
Document any additional information relevant to the sponsor's household members, including your assessment of the safety and well‐being of any children released from ORR care to the sponsor's household members.		(OPEN TEXT)
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Employment Tab

Employment
Proof of Stability
Does the sponsor have a job?					c Yes c No
What is the sponsor’s work schedule?					(OPEN TEXT)
Is the sponsor able to meet their monthly expenses with their income?					c Yes c No
Income
Documents in support of income:
Annual Income	Proof of Income	Employer Name	Employer Address	Employer City		Employer State	Employer Zip Code	Employer Phone	Options
(OPEN TEXT) ($#####.##)	<Dropdown Menu> (-Select- Previous Year’s U.S. Tax Return; Paystubs covering last 60 days continuous; Original letter from employer on company letterhead verifying sponsor’s employment and salary, dated within <60 days; Affidavit of support; Bank statements; Public Assistance Records – TANF; Public Assistance Records – SSI; Public Assistance Records – Cash Assistance; Public Assistance Records – Other entitlement Program; Records of Interest or income earned on assets or investments)	(OPEN TEXT)	(OPEN TEXT)	(OPEN TEXT)		<Dropdown Menu> (-Select State- Alabama; Alaska; Arizona; Arkansas; American Samoa; California; Colorado; Connecticut; Delaware; District of Columbia; Florida; Georgia; Guam; Hawaii; Idaho; Illinois; Indiana; Iowa; Kansas; Kentucky; Louisiana; Maine; Maryland; Massachusetts; Michigan; Minnesota; Mississippi; Missouri; Montana; Nebraska; Nevada; New Hampshire; New Jersey; New Mexico; New York; North Carolina; North Dakota; Northern Mariana Islands; Ohio; Oklahoma; Oregon; Pennsylvania; Puerto Rico; Rhode Island; South Carolina; South Dakota; Tennessee; Texas; Trust Territories; Utah; Vermont; Virginia; U.S. Virgin Islands; Washington; West Virginia; Wisconsin; Wyoming)	(OPEN TEXT)	(OPEN TEXT) (###-###-####)	SAVE
Additional Information
Document any additional information, including your assessment of the sponsor’s ability to support and financially provide for the child while in their care:					(OPEN TEXT)
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Care Plan Tab

Care Plan

Child's Schooling, Health, and Safety

Which school will the child attend?

(OPEN TEXT)

Does the sponsor understand the school enrollment process?

c Yes c No

Who will transport the child to and from school?

(OPEN TEXT)

Is the sponsor aware if the child has any medical, dental, or mental health conditions?

c Yes c No

If Yes, Specify: Please notify the Care Provider Medical Coordinator.

(OPEN TEXT)

What are the sponsor’s plans to address the child’s healthcare needs?

(OPEN TEXT)

Does the sponsor have existing health coverage that the child can be added to as a beneficiary?

c Yes c No

If No, has the sponsor applied for medical coverage, charitable care, or identified healthcare facilities with sliding scale fees?

c Yes c No

If No, would the sponsor like help with this?

c Yes c No

Has the sponsor identified a primary care provider (PCP i.e., pediatrician) for the child?

c Yes c No

If No, what is the plan to obtain a PCP? If Yes, specify provider name or clinic:

(OPEN TEXT)

Has the sponsor identified a dental provider for the child?

c Yes c No

If No, what is the plan to obtain a dentist? If Yes, specify provider name or clinic:

(OPEN TEXT)

IF APPLICABLE: Has the sponsor identified a specialist medical provider for the child’s specific healthcare needs?

c Yes c No c Not Applicable

If No, what is the plan to obtain specialist care? If Yes, specify provider name or clinic:

(OPEN TEXT)

What are the sponsor’s plans to address the child’s mental health care and counseling needs?

(OPEN TEXT)

Is the sponsor able to follow the child’s care plan including filling and administering medications as directed by the healthcare provider and transporting the child to healthcare appointments?

c Yes c No

If No, explain:

(OPEN TEXT)

Does the child have an identified disability?

c Yes c No

*CONDITIONAL LOGIC*: If YES to above; please specify:

c Developmental c Intellectual c Physical c Mental/ Behavioral Health c Other

(OPEN TEXT)

For a child with an identified disability: Describe the steps ORR will take to help the sponsor better understand the child’s needs related to the child’s disability.

(OPEN TEXT)

For a child with an identified disability, describe the assistance and support ORR has provided or will provide the sponsor in accessing appropriate post-release services available in the community.

(OPEN TEXT)

How does the sponsor plan to discipline the child they’re attempting to sponsor?

(OPEN TEXT)

Are there any concerns with the disciplinary practices/ philosophy of the sponsor?

(OPEN TEXT)

Did the sponsor read the Sponsor Handbook?

c Yes c No

Describe how the sponsor plans to keep the child safe and to nurture and support the child through this period of transition and uncertainty?

(OPEN TEXT)

Does the sponsor have any mental health or special needs that would impact their ability to care for the child?

(OPEN TEXT)

If the sponsor has a disability, what, if any, reasonable modifications are required to facilitate the child’s safe release to the sponsor?

(OPEN TEXT)

Supervision Plan

Does the sponsor have any family or community support?

c Yes c No

Describe how the sponsor plans to supervise the child:

(OPEN TEXT)

Does the sponsor have any family friends nearby that will help care for the child?

c Yes c No

Alternate Adult Caregiver Plan

If the sponsor becomes unable to care for the child, who will care for them?

Potential Alternate Adult Caregiver

Primary Alternate Adult Caregiver?

Name

A#

DOB

Age

Sex

Home Address

Phone Number

Relationship to Child

Background Check

Options

c Yes c No

(OPEN TEXT)

(OPEN TEXT)

<POP UP CALENDAR>

SYSTEM GENERATED

<Dropdown Menu> (-Select One - Male; Female, )

(OPEN TEXT)

(OPEN TEXT) (###-###-####)

<Dropdown Menu> ( -Select Relationship – Adult First Cousin; Adult Nephew; Adult Niece; Aunt; Brother; Brother-in-law; Daughter; Daughter-in-Law; Family Friend; Father; First Cousin; Goddaughter; Godfather; Godmother; Godson; Granddaughter; Grandfather; Grandmother; Grandson; Half-sibling; Institutional/ Organizational Sponsor; Legal Guardian; Mother; Nephew; Niece; Other Cousin; Other Distant Relative; Parent’s Partner; Qualified Step Parents; Sister; Sister-in-Law; Son; Son-in-law; Sponsor’s Partner; Stepdaughter; Stepbrother; Stepfather; Stepmother; Stepson; Stepsister; Child’s Spouse; Uncle; Unknown; Unrelated Sponsor)

SYSTEM GENERATED

>|SAVE >|ADD NEW

Has the alternate caregiver’s identity been verified?

c Yes c No

Documents establishing proof of alternate adult caregiver’s identity:

Alternate Adult Caregiver’s Name

Document Type

Expiration Date

Verified by Government Agency

Picture ID

Options

(OPEN TEXT)

<Dropdown Menu> (-Choose an item – US Passport or US Passport Card;; Permanent Resident Card or Alien Registration Receipt Card (I-551); Foreign passport with temporary I-551 stamp; Copy of temporary I-551 notation on machine-readable immigrant visa; Employment Authorization Document with photo (I-766); Foreign passport with Form I-94; Foreign passport with Form I-94A with Arrival-Departure Record & endorsement to work; Passport from the Federated States of Micronesia (FSM) with form I-94 or I-94A; Passport from the Republic of the Marshall Islands (RMI) with form I-94 or I-94A; U.S. Driver’s License or identification card with photo or Name, DOB, Gender, Height, Eye Color, and Address; ID card issued by U.S. federal, state, or local government agencies or entities, with photo or Name, DOB, Gender, Height, Eye Color, and Address; U.S. Military Identification Card; U.S. Military draft record; U.S. Military dependent’s ID card; U.S. Coast Guard Merchant Mariner Card; Native American tribal document; Driver’s License issued by a Canadian government authority; Category 1 Sponsor Only: Other Government-issued photo identity document and seeking exception from ORR under UAC Policy Guide Section 2.2.4, specify below)

<POP UP CALENDAR>

c Yes c No

c Yes c No

SAVE

Additional Information

Document any additional information about the sponsor's plan to care for the child, including your assessment of whether the sponsor will be able to adequately address the care, supervision, safety, education, and resources required to meet the child's needs.

(OPEN TEXT)

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Trafficking and Fraud Tab

Trafficking & Fraud
Sponsor's Journey to the U.S.
When and why did the sponsor first decide to travel to the U.S.?	(OPEN TEXT)
Who planned/ organized the journey?	(OPEN TEXT)
Did the arrangements change during the journey?	c Yes c No
If Yes, how?	(OPEN TEXT)
Did anyone pay for their travel to the U.S.?	c Yes c No
Does that person need to be paid back?	c Yes c No
What does the sponsor believe will happen if that person is not paid back?	(OPEN TEXT)
Does the sponsor’s family or family friend owe money to anyone for the journey?	c Yes c No
If yes, how much?	(OPEN TEXT)
Did the sponsor ever have to depend upon non-family members to provide basic needs such as clothes, food, and housing?	c Yes c No
Did the sponsor experience any challenges, trauma, or abuse by family in home country?	c Yes c No
Where did the sponsor first live in the U.S. and with whom?	(OPEN TEXT)
Has the sponsor traveled back to their country of origin since their arrival in the U.S.?	c Yes c No
Additional Information on sponsor’s Journey to the United States:	(OPEN TEXT)

Coercion Indicators
Did anyone threaten the sponsor or their family?	c Yes c No
If Yes, explain:	(OPEN TEXT)
Was the sponsor ever physically harmed?	c Yes c No
If Yes, explain:	(OPEN TEXT)
Was anyone around the sponsor ever physically harmed?	c Yes c No
If Yes, explain:	(OPEN TEXT)
Was the sponsor ever held against their will?	c Yes c No
If Yes, explain:	(OPEN TEXT)
Did anything bad happen to anyone else in this situation or anyone else who tried to leave?	c Yes c No
If Yes, explain:	(OPEN TEXT)
Did anyone ever keep or destroy the sponsor’s identity documents?	c Yes c No
If Yes, explain:	(OPEN TEXT)
Did anyone ever threaten to report the sponsor to the police or immigration?	c Yes c No
If Yes, explain:	(OPEN TEXT)
Is the sponsor worried anyone might be trying to find them?	c Yes c No
If Yes, explain:	(OPEN TEXT)
Additional information on coercion indicators:	(OPEN TEXT)

Debt Bondage/Labor Trafficking Indicators
Did the sponsor perform any work or provide any services in exchange for the help journeying to the U.S. or for reasons other than to meet basic needs (e.g. food, housing, clothing)?	c Yes c No
Who arranged the work?	(OPEN TEXT)
What type of work did the sponsor perform and where?	(OPEN TEXT)
How often did the sponsor have to work?	(OPEN TEXT)
Did work conditions change over time?	c Yes c No
Is there a debt?	c Yes c No
What is the amount of the debt?	(OPEN TEXT)
Has the debt amount ever increased?	c Yes c No
When did it increase?	(OPEN TEXT)
Why did it increase	(OPEN TEXT)
Has the sponsor or the sponsor’s family ever been threatened over payment or work for the journey?	c Yes c No
If yes, who threatened the sponsor, and how?	(OPEN TEXT)
What did the sponsor think would happen if they left the job or stopped working?	(OPEN TEXT)
Was the sponsor ever made to do work or do anything they did not want to do?	c Yes c No
If Yes, explain:	(OPEN TEXT)
Did the sponsor ever receive pay or did someone else keep the pay?	c Yes c No
Was the sponsor paid what was promised when they started working and were those promises kept?	c Yes c No
Were expenses taken out of pay?	c Yes c No
If yes, what expenses?	(OPEN TEXT)
How did the sponsor get to the work site?	(OPEN TEXT)
Where did the sponsor live while working?	(OPEN TEXT)
Was the sponsor’s freedom of movement ever restricted or closely monitored?	c Yes c No
Was the sponsor ever restricted from communicating or socializing with others, not allowed to speak for themselves, told what to say, or isolated from others?	c Yes c No
Did anyone arrange for the sponsor to work after arriving in the U.S.?	c Yes c No
If Yes, explain:	(OPEN TEXT)
Additional information about debt bondage/ labor trafficking indicators:	(OPEN TEXT)
Child-Sponsor Debt Attestation
Does the sponsor affirm their understanding that the child is not responsible for any debt incurred as a minor, either during their journey to the U.S., or after release; that the child is not authorized to work in the U.S. unless they obtain an Employment Authorization Document from USCIS; and that they will not arrange for or permit for the child to work absent such authorization, nor will they request any type of payment or compensation from the child’s family in exchange for receiving the minor?	c Yes c No
TVPRA
Based on the sponsor assessment, does placement within the sponsor household clearly present a risk of abuse, maltreatment, exploitation, or trafficking to the child?	c Yes c No
If yes, provide a short summary.	(OPEN TEXT)
Referred to OTIP?	c Yes c No
Based on the sponsor assessment, does the sponsor clearly present a risk of abuse, maltreatment, exploitation, or trafficking to the child?	c Yes c No
If yes, provide a short summary. Note: If the answer is yes, the case must be referred for a mandatory home study.	(OPEN TEXT)
Fraud
Has the sponsor ever been contacted and asked to pay fees/money related to the release of the child	c Yes c No
If yes, explain.	(OPEN TEXT)
Has the sponsor ever been contacted and asked to pay fees/money related to the release of the child they previously sponsored or attempted to sponsor and not reported it to ORR?	c Yes c No
If yes, explain.	(OPEN TEXT)
Additional Information
Use this section to report any additional information that may be pertinent to the sponsor's assessment that has not been covered in the sections above or that requires further elaboration.	(OPEN TEXT)
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Flags Tab

New Flag
Flag Type*	<Dropdown Menu> (-Select One- Sponsor; Household Member; Alternative Caregiver; Address)
Name*	*CONDITIONAL LOGIC* based on Flag Type selection	If Sponsor…	Auto-Populate Sponsor Name; Source: Sponsor Demographic Information section above
		If Household Member…	<Dropdown Menu> (-Select One- *Auto-populate household member names) Source: Household section above.
		If Alternate Caregiver…	<Dropdown Menu> (-Select One- *Auto-populate alternative caregiver names) Source: Care Plan section above
		If Address…	Auto-Populate Address; Source: Contact Information section of above.
Flag Category*	*CONDITIONAL LOGIC* based on Flag Type selection	If Sponsor…	<Dropdown Menu> (-Select One- Criminal Activity or Charges; Document/ Information Fraud; Suspicion of Trafficking a Child; Failed to enroll Child in school; Did not report child left the home; Not helping child with their immigration requirements; Not providing for child’s basic needs (ex. Food, clothing, or a bed); Child is not receiving necessary medical/ mental health care; Abandonment of child; CPS involvement; Trafficking and/ or exploitation concerns involving sponsor’s employer/ industry; Loss of contact with sponsor or child during post release services with safety concerns)
		If Household Member or Alternative Caregiver…	<Dropdown Menu> (-Select One- Criminal Activity or Charges; Document/ Information Fraud; Suspicion of Trafficking a Child; Confirmed Trafficking of a Child; CPS Involvement)
		If Address…	<Dropdown Menu> (-Select One- Home Study Determination of substandard housing; Used for previous sponsorships; concerning activity identified at address (ex: trafficking, sexual abuse)
Flag Description*	(OPEN TEXT)
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Sponsor Assessment Summary Tab

Unification Specialist Assessment
Sponsor Suitability Recommendation:	<Dropdown Menu> (-Select one- Positive; Negative)
Post-Release Services Recommendation:	<Dropdown Menu> (-Select one- None; Level 1; Level 2; Level 3)
Home Study Recommendation:	<Dropdown Menu> (-Select one- None; Discretionary; ORR Mandated; TVPRA)
Explain rationale for these recommendations, highlighting any concerns about the sponsor’s ability to safely care for and provide for the child’s individual needs and well-being:	(OPEN TEXT)
*CONDITIONAL LOGIC* If YES selected under Care Plan section: For a child with an identified disability: Describe how the Sponsor Suitability Recommendation considers the assistance ORR must affirmatively provide to the potential sponsor of a child with a disability.	(OPEN TEXT)

Case Manager Assessment
Provide a thorough assessment of the sponsor's ability to safely care for the child, provide for the child's individual needs, and ensure the safety and well‐being of the child. Include discussion of the potential benefits to the child resulting from placement with this sponsor in this community.	(OPEN TEXT)
Do you have any outstanding concerns related to the child’s disability?	c Yes c No c Not Applicable
If you answered “Yes”, describe the steps ORR will take to help the sponsor better understand the child’s needs related to the child’s disability, the post-release services ORR will assist the sponsor in coordinating, and whether these efforts will enable the child’s safe release.	(OPEN TEXT)
If you answered “Yes”, describe whether ORR has taken all actions contemplated by the transition plan in the child’s 504 Service Plan. (as applicable).	(OPEN TEXT)
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Certification Tab

Certification

Do not complete this section until you have finalized the Sponsor Assessment and are ready to Submit. By completing this section, you certify that the assessment is complete and the information contained within is current, complete, and accurate to the best of your knowledge.

Date Initiated:

SYSTEM GENERATED/ AUTO POPULATED

Date Completed:

<POP UP CALENDAR>

*CONDITIONAL LOGIC* <IF “DATE COMPLETED” > 5 Calendar days post DATE INITIATED; THEN open dialog box and prompt for explanation:

"Per UAC Manual of Procedures Section 2.4.1 – Assessment Criteria, the sponsor assessment should be completed within five calendar days of identifying a sponsor, or as soon as practicable for the sponsor. Please explain factors which delayed completion:”

<CONDITIONAL POP UP> (OPEN TEXT)

Signature:

(OPEN TEXT)

Title:

(OPEN TEXT)

Was an interpreter or translation service used in the performance of this assessment?			c Yes c No
If yes, Specify:
Interpreter Name:	(OPEN TEXT)	Interpreter language:		<Dropdown Menu> (-Select One- See Ref. Table 1: Languages)
Interpreter Signature	(OPEN TEXT)	Date:		<POP UP CALENDAR> MM/DD/YYYY

< Prev.

>| Save

APPENDIX

Reference Table 1: Languages

<Dropdown Menu> ( - Select Language – Spanish; Acateco; K’iche’; Q’eqchi; Mam; Non-verbal; Sign Language; Unknown Dialect; Achi; Albanian; Arabic; Armenian; Asante; Awakatek; Azerbaijani; Bambara; Bengali; Cantonese Chinese; Chatino; Chechen; Chorti; Chuj; Creole – Haitian (French); Creole – Spanish; Czech; Dari; Dutch; Eman; English; Ewe; Fanti; Farsi (Persian); French; Fujianese; Fulani; Fuzhou; Ga; Garifuna; Georgian; German; Gujarati; Haryanvi; Hausa; Hebrew; Hindi; Hungarian; Italian; Ixil; Jacatelco (Popti); Japanese; Kaqchikel; Kikongo; Korean; Kotokoli; Kurdish; Kyrgyz; Lachi; Latvian; Lenka; Lingala; Malinke; Mandarin Chinese; Mandingo; Marwari; Maya; Mazatec; Miskito; Mixteco; Mopan; Nahuatl; Nepali; Otomi; Pashai; Pashto; Patois; Polish; Poqomam; Poqomchi; Portugese; Pular; Punjabi; Qanjobal; Quechua; Rohingya; Romani (Gypsy); Romanian; Russian; Serbian; Sipakapense; Slovak; Somali; Soinke; Susu; Swahili; Sylheti; Tajik; Tamil; Tarahumara; Tectiteco; Telugu; Thai; Thibetan; Tigrinya; Tlapanec; Tojolabal; Triqui; Turkish; Twi; Tzeltal; Tzotzil; Tz’utujil; Ukranian; Urdu; Uspanteko; Uzbek; Vietnamese; Wolof; Yoruba; Zaghawa; Zapotec; Zarma; Zoque)

S-5 | Version #.#

Valid Through MM/DD/YYYY

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