Form 1 URM Withdrawal or Declination of Particiapation

OMB Control No: 0970-XXXX

Expiration date: XX/XX/XXXX

Unaccompanied Refugee Minors (URM) Program

U.S. Department of Health and Human Services (HHS)

Office of Refugee Resettlement (ORR)

Division of Children’s Services (DCS)

Date:	Alien Number (if applicable):
Minor’s First Name(s):	Minor’s Last Name(s):
Assister:	Agency:

WITHDRAWAL OF APPLICATION

I applied for the URM Program on _________ (date). I received an explanation of the program, its services, and my potential rights and responsibilities from ____________________ (name) on _________ (date) in _____________ (language) and understand the information that was presented to me. I hereby choose to withdraw my URM application. I understand that by withdrawing my URM application at this time, I may not be able to enter the program at a later date.
Signature of Minor :	Signature of Witness (different from assister):
Interpreter, if applicable: I read this Withdrawal of Application from the URM Program form to ______________________ (name) on ___________ (date) and they asserted that they understood the form and the consequences of withdrawing their URM application.

REFUSAL OF PARTICIPATION

I applied for the URM Program on _________ (date). I received an explanation of the program, its services, and my potential rights and responsibilities from ____________________ (name) on _________ (date) in _____________ (language) and understand the information that was presented to me. I hereby decline to enter the URM Program. I understand that if I decline to enter the URM Program at this time, I may not enter the program at a later date.
Signature of Minor :	Signature of Witness (different from assister):
Interpreter, if applicable: I read this Refusal of Participation in the URM Program form to ______________________ (name) on ___________ (date) and they asserted that they understood the form and the consequences of declining participation in the URM Program.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 0.1 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.