Letter of Designation for Care of a Child

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OMB 0970-0278 [valid through MM/DD/YYYY

Administration for Children & Families
Office of Refugee Resettlement

Letter of Designation for Care of a Child
Your child has been designated as an unaccompanied alien child (UAC) and placed into the care and custody of the Office
of Refugee Resettlement (ORR), pursuant to 6 U.S.C. § 279 and 8 U.S.C. §1232. ORR has authority under the law to release
your child to a sponsor, typically an adult relative. ORR prefers sponsors to be parents or legal guardians.1 In the event
that you are unavailable to sponsor your child, ORR asks that you designate a sponsor to care for your child (subject to
ORR's approval).
I/We are the parent(s) or legal guardian(s) of
born on
Your Child's Date of Birth

.

I/We designate

,

Your Child's Full Name

to sponsor my/our child.
Proposed Sponsor's
Name

I/We consent that the above-named sponsor may:
• Have temporary caregiving authority for my child, until such time as my child is returned to my custody; or
his/her custody status is altered by a Federal, State, or local agency; or changed by a court of law.
• Provide medical, dental, and mental health care for my child.
• Provide for my child's physical and mental well-being, including but not limited to providing food, shelter,
and clothing.
• Enroll my child in school.
• Temporarily transfer physical custody of my child in the event of an emergency (serious illness,
destruction of home, etc.) to another person who will comply with the Sponsor Care Agreement.
I/We understand that this designation does NOT:
• Terminate my parental rights.2
• Confer upon the sponsor any rights or benefits.
• Allow my child permission to work in the United States without proper authorization.
1 Individuals are not required to be U.S. citizens or hold any immigration status in order to sponsor a child.
2 Please note that by signing this form you are NOT terminating your parental or guardianship rights to your child. You maintain legal custody over your child pursuant
to relevant Federal and State law. ORR encourages you to stay in close contact with your child and the child's sponsor in order to help make decisions for the child's
care and for medical, educational, and other service. Please also note that if you do not designate a sponsor, ORR may transfer custody of your child to a sponsor
identified by ORR.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 0.75 hours per response, including the time for
reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. Please see the accompanying privacy notice / Privacy Act statement for a discussion of (1) the
authority for solicitation of information, and whether disclosure is mandatory or voluntary, (2) the principal purposes for which the information is intended to be used, (3) other routine uses
which may be made of the information, and (4) the effects, if any, of not providing all or any part of the requested information. If you have any comments on this collection of information
please contact [email protected].

Sponsor Application Packet | Version 19
SAP-6 (ENG) Letter of Designation for Care of a Child
Revised MM/DD/YYYY

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Letter of Designation for Care of a Child
Office of Refugee Resettlement

Name of parent(s) or legal guardian(s) designating care:
(1)
Printed Name
(2)
Printed Name

If one of the child's biological parents or legal guardian(s) is unable to consent please check why:
Mentally or physically unable to provide consent

Deceased

No longer has legal custody of the child

Abandoned child
Other parent/legal guardian resides
in another location (ORR may contact
them separately)

Other (Explain briefly):

Parent(s) or legal guardian(s)' contact information:
Street Address
City

State

Zip Code

Phone
Parent(s) or legal guardian(s)' signature consenting to the designation of care for their child:
I declare and affirm under penalty of perjury that the information contained in this authorization is true and accurate to
the best of my knowledge. I understand that knowingly and willfully falsifying, concealing, or covering up a material fact,
or making any materially false, fictitious, or fraudulent statement or representation, or making or using any false writing or
document knowing it contains any materially false, fictitious, or fraudulent statement or entry, is a violation of 18 U.S.C. §
1001 and may subject me to fines, imprisonment, or both. ORR may report fraudulent information to Federal law
enforcement. (Sign, date, and print your name)

NOTARY SEAL

(1)
Signature

Date

Signature

Date

(2)

Sponsor Application Packet | Version 19
SAP-6 (ENG) Letter of Designation for Care of a Child
Revised MM/DD/YYYY

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Letter of Designation for Care of a Child
Office of Refugee Resettlement
STAFF USE ONLY - The Federal Field Specialist must complete this section if they assisted the sponsor applicant with
entering information into this form.
I attest under penalty of perjury that to the best of my knowledge:
• Any information I entered into this form on behalf of the sponsor applicant is an accurate and
complete representation of information provided to me by the sponsor applicant; and
• I have not altered or otherwise misrepresented the information provided by the sponsor applicant.

Federal Field Specialist Signature

Federal Field Specialist Name

Sponsor Application Packet | Version 19
SAP-6 (ENG) Letter of Designation for Care of a Child
Revised MM/DD/YYYY

Date

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