Sponsor Application

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OMB 0970-0278 [valid through 02/28/2029]
Administration for Children & Families
Office of Refugee Resettlement

Sponsor Application
Sponsor Information

    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 birth
Where you were born?
    5) Your date of birth
month/day/year (e.g., 12/31/1979)
    6) Language(s) you speak
    7) Sponsor’s Contact Information
e.g., 210-555-1234	Mobile  Phone

Secondary Phone

Email Address




    8) Your email address

Sponsor’s Income and Employment Information
 
Are you providing court ordered financial support to children? 	 Yes	 No

Are you receiving child support?				 Yes	 No
Do you have a job?						 Yes	 No
If no, how do you earn money?
If yes, please answer the following questions.
My Job

Type of Employment/Position Title/Job Title

Weekly Average Income

Annual Income 

Employer Name

Employer Street Address

Employer City

Employer Country

Employer State/Territory

Employer Postal Code

Employer Phone

Start Date of Employment
	Employment Start Month 
Employment Start Year
Length of Employment

Average Total Hours Worked per Week

Days Worked per Week on Average
                • Monday
                • Tuesday
                • Wednesday
                • Thursday
                • Friday
                • Saturday
                • Sunday

Comment 


Are you financially supported by the Household Members, 		 Yes	 No
a partner, Alternative Caregiver, or spouse? 		
							 
If yes, please answer the following questions.
My Supporter’s Job
Type of Employment/Position Title/Job Title
Weekly Average Income
Annual Income 
Employer Name 
Employer Street Address
Employer City 
Employer Country
Employer State/Territory
Employer Postal Code
Employer Phone 
Start Date of Employment
	Employment Start Month 
Employment Start Year
Length of Employment
Average Total Hours Worked per Week
Days Worked per Week on Average
                • Monday
                • Tuesday
                • Wednesday
                • Thursday
                • Friday
                • Saturday
                • Sunday

Comment 


Are you able to meet and pay for all of your expenses? 	 Yes	 No
What are your other sources of income?		

List your monthly expenses for: 
Food-Average cost per month

Rent-Average cost per month

Clothing – Average Cost per month

School Needs – Average Cost per month

Total Monthly Expenses 		Total Monthly Income 		Total Annual Income 




Prior Sponsorship Information
Have you ever attempted to sponsor a child in ORR Care?		  Yes	 No
If yes, please answer the following. 
Date of Sponsorship 
Child’s UAC Portal ID
Child’s A#
Child’s First Name
Child’s Last Name
Child’s Date of Birth
Child Sex
Your relationship to this child
Is/Was the child enrolled in or attending school? 			 Yes	 No
Did the child attend their immigration court date?			 Yes	 No
If yes, what was the court date? 
Has the Child received Post Release Services from ORR? Has a case		    Yes   No
manager been in touch to support the child?

Is the child you sponsored still residing with you?			 Yes   No
Have you ever had an ORR Home Study for your sponsorship?		 Yes	 No
Have you ever withdrawn or discontinued an application to sponsor a child? 	 Yes	 No
If yes, why did you withdraw? 
Have you ever been told no when trying to sponsor a child?    	  Yes	 No
If yes, why? 
Do you have any relatives in ORR care?		 Yes	 No
Have you ever had a child removed from your custody?		 Yes	 No
If yes, Explain. 

Household Information

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

City	State 	Zip code	
 	If this is not the same as your current address, please explain. 


    10) Who else currently lives at this address?
Include everyone who lives at this address, except yourself. A phone number and email address for adults (ages 18 or older).

Household Member First and Last Name
Date of
Birth
Relationship to you (the sponsor)
Relationship to the child
Phone Number
Email Address
(EXAMPLE) Miguel
12/31/1985
Brother
Uncle
555-555-5555
[email protected]












Health Information
14a) Does any person in your household have any serious contagious diseases (TB, AIDS, hepatitis, etc.)?
If yes, please explain:



 Yes	 No

14b) Are you aware of any health conditions the child(ren) may have (disabilities,
allergies, diseases, etc.)?	Yes	 No
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 8 of this packet) for more information.

15a) Have you or any person in your household ever been charged with or convicted of a crime (other than a minor traffic violation; e.g. speeding, parking ticket, etc.)?   			Yes	 No
If yes, please answer the following questions.

Incident (Add button visible for multiple incidents to report)
Name of household member(s) involved
Place of incident
Date of the incident
Explanation of the incident 
Disposition of the incident e.g. charges dropped, fined, imprisoned, probation


15b) Have you or any person in your household ever been investigated for physical abuse, 
sexual abuse, neglect, or abandonment of a minor?  		   Yes	 No

If yes, please answer the following questions. 

Abuse or Abandonment

Name of household member(s) involved 
Place of incident
Date of the incident
Explanation of the incident 
Disposition of the incident e.g. charges dropped, fined, imprisoned, probation


15c) Have you or anyone in your household 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?

Adult Who Will Care for the Child(ren) if You Cannot
If you become unable to care for the child(ren), who will care for the child(ren)?

12a) Name of potential adult caregiver


12b) Date of birth of potential adult caregiver

12c) Contact information of potential adult caregiver	Phone Number

									Email Address
Street Address
(+ apartment number, if applicable)

City	State/Territory		Postal code


Country 


12d) What is their relationship to the child(ren)?
(grandparent, aunt, sibling over 18 years old, etc.)

12e) What is their relationship to you, the sponsor?

12f) If you become unable to care for the child(ren), how will the alternative caregiver care for the children? 

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.

YOUR SIGNATURE	DATE




Supporting Documents
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 yourself, each adult member of your household, and the alternative caregiver 
    a. Identification Documents: 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 for yourself and each adult member of your household. Expired documents will not be accepted.
    b. Sponsor photo (selfie). All potential sponsors must provide a current photo of themselves (selfie) to support verification of their identity.
Acceptable Proof of Identity Documents
U.S. Passport or U.S. Passport Card
Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
Employment Authorization Document that contains a photograph (Form I-766)
Foreign passport with Form I-94 or Form I-94A with Arrival-Departure Record, and containing an endorsement to work
Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
Driver’s license or ID card issued by a U.S. state or outlying possession of the United States provided it contains a photograph or information such as a name, date or birth, sex, height, eye color, and address
ID card issued by U.S. federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, sex, height, eye color, and address
U.S. Military card or 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
    3) Legal Records (if applicable)
If you answered “YES” to either question 15(a) or 15(b) on this form, please provide us with the following information for each charge/conviction:
        ◦ 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 Address
An original version of at least one form of documentation verifying your current address. Acceptable forms of documentation include:
        ◦ Your current lease with your name
        ◦ Your current mortgage statement with your name, dated within the last month before submission of this application
        ◦ A valid, unexpired state ID with your current address and photo
        ◦ A utility bill, addressed to you at your current address, dated within the last month before submission of this application
        ◦ Your bank statement dated within the last month before submission of this application
        ◦ A payroll check stub issued by your employer, dated within the last month before submission of this application
    5) Proof of Income
Legible full color photocopy, digital scan, high-resolution digital photo, or original version of at least one form of documentation verifying your income. Acceptable forms of documentation include:
        ◦ Previous year’s tax return (if in the United States during that year)
        ◦ Copies of paystubs for the past consecutive 60 days;
        ◦ An original letter from your employer, signed within the past 60 days, verifying employment and salary. o	The letter must be on company letterhead and contains verifiable contact information for the
employer and supervisor.
            ▪ An ORR Representative must speak with the supervisor or company Human Resources division to verify the information in the letter.
        ◦ Documentation of:
            ▪ Income received from assets (for example, a 1099-INT tax form from the previous year or receipts from rental income received covering the last 60 days) or investments

            ▪ Unemployment benefits
            ▪ Strike pay
            ▪ Gifts
            ▪ Annuities
            ▪ Alimony
            ▪ Proceeds from a settlement
        ◦ Public Assistance Records:
            ▪ Temporary Assistance for Needy Families (TANF)
            ▪ Supplemental Security Income (SSI)
            ▪ Cash Assistance
        ◦ A balance page from the sponsor’s most recent quarterly bank statement
        ◦ Affidavit of Financial Support (Form SAP-8) (multiple forms may be submitted)

    6) 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.

Your Relationship to the Child
Acceptable Documents

Parent
    • Birth certificates
    • Court records
    • Parent's government-issued photo ID

Step-Parent
You have legally adopted the child
    • Birth certificates
    • Parent's government-issued photo ID
    • Step-Parent's government-issued photo ID
    • Marriage certificate
    • Court order documents confirming adoption or legal guardianship has been established


Legal Guardian
    • Court order documents confirming adoption or legal guardianship has been established
    • Birth certificates
    • Legal guardian's government-issued photo ID
    • Guardianship records
    • Death Certificates




Family Member
    • Birth certificates
    • Trail of familial birth and/or death certificates showing that you and the child are related
    • Marriage certificates
    • Court records
    • Written affirmation of relationship from your Consulate
You are not related to
the child
Please contact your Federal Field Specialist

    7) Reason you are unable to provide all the documents we ask for (if applicable)