Form 1 State Request for Federal Support Form

OMB Control No: 0970-xxxx

Expiration date: xx/xx/xxxx

DEPARTMENT OF HEALTH & HUMAN SERVICES ADMINISTRATION FOR CHILDREN AND FAMILIES 370 L’Enfant Promenade, S.W., Washington, D.C. 20447 U.S. REPATRIATION PROGRAM Emergency and Group Repatriation State Request for Federal Support Form ( NOTE: Use additional pages where space on this form is insufficient or continue on reverse side)
instruction: This form is to be completed by an official authorized by the State to request support from a Federal agency
(1) Requestor Name and Title				(2) State		(3) Date and Time Submitted
						Date	Time
Type of Assistance Requested and Description: Attach supportive document or justification as needed
Requestor E-mail:				Location Where Service/Support is Needed
Requestor Telephone:
Requestor Signature Date:
To be Completed by ACF authorized staff This request is to be reviewed by the Financial Officer and approved by ACF authorized Official
ACF Financial Officer Name (print):_________________________________________ Sign:__________________________________________ Date/Time request was received from the State ______\_______\___________ Time ____________________
Federal AGENCY/INDIVIDUAL ASSIGNED TO EXECUTE THIS REQUEST
Date assigned
name of federal POINT OF contact (poc)
poc title
Poc telephone
poc e-mail
Authorized ACF Official
ACF Official Signature					Date

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average 0.15 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.

Personal information provided on this form may only be disclosed for program purposes or under the conditions prescribe in 45 CFR 211.14 or 212.9.