Sponsor Application

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

Administration for Children & Families
Office of Refugee Resettlement

Sponsor Application for Ms. L Separation Cases
About you - the sponsor - and the child(ren)
1) Name(s) of the child(ren)
List the names of all children you are applying to sponsor

Your relationship to the child(ren)
e.g., mother, uncle, family friend

2) Your Name
3) Other names you have used
List other names you have used, such as your
name before you were married or maternal
last names (separate with commas)
4) Your country of origin
Where you were born
5) Your date of birth
month/day/year (e.g., 12/31/1979)
6) Phone numbers
e.g., 210-555-1234

Primary Phone
Secondary Phone

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 1.0 hour 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-9 (ENG) Sponsor Application for Ms. L Separation Cases
Revised MM/DD/YYYY

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Sponsor Application for Ms. L Separation Cases
Office of Refugee Resettlement
7) Your email address
8) Language(s) you speak

Where will you and the child(ren) live?
9) Address
Street Address
(+ apartment number, if applicable)
City

State

Zip code

Financial Information
10) How will you financially support the child(ren)?
Include all sources and amounts of your income (for example, the amount you are paid each week) as well
as explaining any financial support from others who will help financially support the child(ren).

Health Information
11) Are you aware of any health conditions the child(ren) may have (disabilities,
allergies, diseases, etc.)?

Yes

No

Need Help? Contact your sponsor specialist.
Sponsor Application Packet | Version 19
SAP-9 (ENG) Sponsor Application for Ms. L Separation Cases
Revised MM/DD/YYYY

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Sponsor Application for Ms. L Separation Cases
Office of Refugee Resettlement

If yes, please explain:

Criminal History
If you answer “YES” to either of these questions, you will need to provide more information. See the Supporting
Documentation section of this form (page 6 of this packet) for more information.
13a) Have you ever been charged with or convicted of a crime (other than a minor
traffic violation; e.g. speeding, parking ticket, etc.)?

Yes

No

13b) Have you ever been investigated for the physical abuse, sexual abuse, neglect,
or abandonment of a child?

Yes

No

Yes

No

13c) Have you ever committed, agreed to commit, asked someone else to commit,
helped commit, or tried to commit a crime or offense for which you were NOT
arrested?

Sign & Date Your Application

I declare and affirm under penalty of perjury that the information contained in this application is true and
accurate to the best of my knowledge.
I attest that all documents I am submitting or copies of those documents are free of error and fraud.
I will provide for the physical and mental well-being of the child(ren). I will also comply with my state's laws
regarding the care of this child including:
• Enrolling the child(ren) in school;
• Providing medical care when needed;
• Protecting the child(ren) from abuse, neglect, and abandonment; and
• Any other requirement not herein contained.
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.

Need Help? Contact your sponsor specialist.
Sponsor Application Packet | Version 19
SAP-9 (ENG) Sponsor Application for Ms. L Separation Cases
Revised MM/DD/YYYY

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Sponsor Application for Ms. L Separation Cases
Office of Refugee Resettlement

YOUR SIGNATURE

DATE

STAFF USE ONLY - The Federal Field Specialist (FFS) 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.

FFS Signature

FFS Name

Date

Need Help? Contact your sponsor specialist.
Sponsor Application Packet | Version 19
SAP-9 (ENG) Sponsor Application for Ms. L Separation Cases
Revised MM/DD/YYYY

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Sponsor Application for Ms. L Separation Cases

Supporting Documents

Office of Refugee Resettlement

Please provide the following documents. If you are unable to provide the documents we ask for, please
explain why in the textbox below and contact your Federal Field Specialist. We may reject your application if
any of the required information is missing, incomplete, or inaccurate.
1) Proof of Child's Identity
Legible full color photocopy, digital scan, high-resolution digital photo, or original version of the child's birth
certificate
2) Proof of Identity for you
Legible full color photocopies, digital scans, high-resolution digital photos, or original versions of
government-issued identification documents. You must present at least one selection from the list below.
Expired documents will not be accepted.
3) Legal Records (if applicable)
If you answered “YES” to either question 13(a) or 13(b) on this form, please provide us with the following
information for each charge/conviction:
• Name of person involved
• Place and date of the incident
• Explanation of the incident
• Disposition of the incident (e.g., charges dropped, fined, imprisoned, probation, mandated or
voluntary classes, counseling, or other required actions that were part of a plea agreement or court
agreement)
• Legible full color photocopies, digital scans, high-resolution digital photos, or original
versions of court record(s), police record(s), and/or governmental social service agency
record(s) related to the incident(s)
4) Proof of Relationship
Legible full color photocopy, digital scan, high-resolution digital photo, or original version of at least one
document to provide proof of a relationship between you and the child.
We may consider other similar documents not included in this list.
• Birth certificates
• Other government-issued certificates or guardianship records
• Hospital or educational records
• Court records
• Consular documents

Need Help? Contact your sponsor specialist.
Sponsor Application Packet | Version 19
SAP-9 (ENG) Sponsor Application for Ms. L Separation Cases
Revised MM/DD/YYYY

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Sponsor Application for Ms. L Separation Cases
Office of Refugee Resettlement
5) Reason you are unable to provide all the documents we ask for (if applicable)

Need Help? Contact your sponsor specialist.
Sponsor Application Packet | Version 19
SAP-9 (ENG) Sponsor Application for Ms. L Separation Cases
Revised MM/DD/YYYY

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