Form 1 URM Program Application Form

OMB Control No: 0970-XXXX
Expiration date:

UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM APPLICATION
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)
OFFICE OF REFUGEE RESETTLEMENT (ORR)

Please complete all sections of this application. Send any questions to URMprogram@acf.hhs.gov.
Use the “Submit” button at the end of this form to send the application via e-mail to
URMprogram@acf.hhs.gov
Please Check if:
 Resubmission of an application (Describe in Section 4.7)
 Application is URGENT (Applicant will turn 18 years of age within 45 calendar days or less from the submission
date of this application.)

Date of Application 
Section 1—Assister Information
Complete the following if you are assisting a minor with this application.
First Name(s) 

 Last Name(s) 

Title(s) 

 Agency Name 

Agency Address 

 State 

Phone Number 

 Zip Code 

 Email 

Signature of Assister(s) 
Relationship to minor 

Provide digital signature. Or print page 1, sign and e-mail as an attachment with this form.

 Attorney 

 Authorized Representative 

Case Manager

 Other (please describe) 

Section 2—Minor’s Consent
If the minor is 12 years of age or older, please complete the consent form below.

By signing below, I consent to the submission of my application to the Unaccompanied Refugee Minors (URM) program. I have been advised and understand the information about the URM program,
placement and services that I may be eligible to receive. I also understand that ORR will review my
application for eligibility and submit a decision to the adult(s) and/or agency named above.
Signature of Minor 

Provide digital signature. Or print page 1, sign and e-mail as an attachment with this form.

Signature of Witness 

(different from assister) Provide digital signature. Or print page 1, sign and e-mail as an attachment with this form.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to collect
information on an unaccompanied minor interested in participating in the Unaccompanied Refugee Minors Program. Public reporting burden for this collection of
information is estimated to average 1.5 hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the
collection of information. This is a mandatory collection of information (8 U.S.C. 1522(d)). An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number.
The OMB # is 0970-XXXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Anne Mullooly in
the Office of Refugee Resettlement at Anne.Mullooly@acf.hhs.gov.

URM Program Application • PAGE 2 OF 15

Section 3—Minor’s Biographical Information
First Name 

 Middle Name 

 Last Name 

All Other Names Used 
Gender 

 Female

 Male Age 

 Date of Birth 

 Country of Birth 

Alien Number (if applicable) 

 Primary Language 

ENGLISH PROFICIENCY

MARITAL STATUS

 Conversational
 Requires an Interpreter
 Tested Proficient

 Single
 Married
 Divorced

Date First Entered ORR Custody (if applicable) 
Attach each document used to verify the age and identity of minor
 Birth Certificate   Forensic Dental Scan   DOJ/DHS Immigration Doc 
 UNHCR BID Report   Other (please describe below) 

 Bone Density Scan 

Does the minor have children in the U.S.?   Yes    No
If yes, please provide the name(s) and date(s) of birth 

Immigration status

Verification document(s) (check attached document(s))

 Refugee
I-94
 Asylee
 Asylum Letter
 Cuban/Haitian Entrant
 I-862
 Victim of Human Trafficking
 Eligibility Letter
 Special Immigrant Juvenile
 I-360 Approval Notice
 U Status Recipient
 U-Visa
If “other” is selected, please describe document(s) below:

I-94
I-94
T-visa
I-485 Approval Notice
I-797

Section 4—Placement Information
Current Placement 
Current caregiver 
Placement contact information 
If the minor is in ORR custody, please provide the date the minor entered their current placement 

 Other 
 Other
 Other
 Other
 Other
 Other

URM Program Application • PAGE 3 OF 15
If the minor is not in ORR custody, please describe why continuing with their current caregiver is not possible or is not
in the minor’s best interest:

Current placement type:
Relative
Residential Treatment
Sponsor (non-relative)  
Therapeutic Group Home

 Basic Foster Home
 Secure Care  
Staff Secure

Regular Group Home  
Shelter Care  
Therapeutic Foster Home
Other

If relative is selected, please provide more details:

If the minor is in ORR custody and the agency also provides URM placements:
Is there a recommendation, if approved for the URM program, that the minor remain in their current placement or
another placement provided by the same agency?   Yes   No   Not Applicable

URM Program Application • PAGE 4 OF 15
If yes, please include a placement assurance memo. The placement memo should:
 Describe the placement.
 Provide sufficient information for ORR to verify that the placement being offered is a URM placement with the
same agency. For example, include a name, location, and/or other information which demonstrates that the recommendation and offered placement are the same, or that a new placement has been identified.
 Include a point of contact (including title) with authority to determine placements within the agency.
 Provide any details necessary to ensure that legal responsibility can be established.
Preferred Placement:
Does the minor have a preferred location and/or placement type within the URM program? 
If yes, please indicate the location and/or placement type(s):

 Yes

 No

Does the assister have a recommended location and/or placement type within the URM program? 
If yes, please indicate location and/or placement type(s):
Basic foster home
  Therapeutic foster home
  Regular group home
Therapeutic group home
  Semi-independent living
Other

 Yes 

 Basic foster home
Therapeutic group home

 Therapeutic foster home
 Semi-independent living

 Regular group home
 Other

If other, please describe:

Please provide the reason for this selection(s):

If other, please describe:

 No

URM Program Application • PAGE 5 OF 15
Please provide the reason for this selection(s):

Section 4.1—Custody Information
Does an entity or individual in the U.S., other than ORR, have legal responsibility for the minor? 
If yes, please explain and provide a copy of the relevant court order:

 Yes 

 No

Are there known barriers which could prevent or delay a state’s ability to arrange legal responsibility for the minor?
 Yes   No
If yes, please describe:

Is there a state or local court hearing pending for this applicant?   Yes   No
If yes, please explain (provide date, type and city/state) and attach a copy of the hearing notice, if available:

URM Program Application • PAGE 6 OF 15
Is there a dependency or SIJ findings order for this minor?    Yes   No
If yes, please indicate the date and court of jurisdiction and attach a copy of the order:

Section 4.2—Family Reunification/Sponsor Information
Please provide the location of the minor’s biological parent(s) or legal guardian(s) and evidence, if any, that each is unwilling/unable/unsuitable to care for the minor. Attach the following, if the minor is in ORR custody and if applicable:
Home studies, third party recommendations, reunification denial letters, and denied Release Request Worksheets.
Mother:

Father:

Other:

URM Program Application • PAGE 7 OF 15
Does the minor know of a non-parental relative or unrelated adult residing in the U.S.?
 Yes   No
Describe such relatives or unrelated adults, include relationships to child, provide location(s) in the U.S and describe
evidence, if any, that the relative(s) or unrelated adult(s) is/are unwilling/unable/unsuitable to care for the minor:

Section 4.3—Behavioral Health Information
Does the minor have a history of juvenile delinquency?
If yes, please explain and attach documentation, if available:

 Yes 

 No

Does the minor’s placement history include incident reports, such as ORR Significant Incident Reports (SIRs)?
 Yes   No
If yes, please explain and attach the reports:

URM Program Application • PAGE 8 OF 15
Does the minor have a history of substance use?   Yes 
If yes, please explain and attach documentation, if available:

No

Does the minor have a history of being destructive with property? 
If yes, please explain and attach documentation, if available:

Is the minor a danger to themselves or others? 

 Yes 

If yes, please explain and attach documentation, if available:

 No

 Yes 

 No

URM Program Application • PAGE 9 OF 15
If the minor is in ORR custody, is a copy of the UC Assessment and Case Review attached to this application?
 Not Applicable   Yes   No If no, please explain:

Are there any other safety or security risks?   Yes   No
If yes, please explain and provide recommendations for safety planning:

Section 4.4—Physical Health and Mental Health Information
Does the minor have a diagnosis for a mental health condition?  
If yes, please explain:

 Yes 

 No

URM Program Application • PAGE 10 OF 15
Has the minor been hospitalized or received residential treatment for a mental health reason? 
If yes, please explain and attach documentation, if available:

Does the minor have a history of receiving mental health services?  
If yes, please explain and attach documentation, if available:

 Yes 

 No

Does the minor take prescription medications for physical or mental health issues?  
If yes, please explain:

 Yes 

 Yes 

 No

 No

URM Program Application • PAGE 11 OF 15
Does the application include a copy of the minor’s most recent clinical assessment? 
If yes, please identify the document:

 Yes 

If no, please explain:

Does the minor self-report a history of significant trauma? 
If yes, please explain:

 Yes 

 No

Does the minor have any medical concerns that could impact placement?
If yes, please explain:

 Yes 

 No

 No

URM Program Application • PAGE 12 OF 15
Does the minor require accommodations for a disability? 

 Yes 

 No

If yes, please explain:

Section 4.5 —Educational and Employment Information
Is the minor currently enrolled in an educational program? 
If no, please explain:

 Yes 

What is the highest educational level completed by the minor?

Please describe the minor’s educational goals:

Please describe the minor’s employment goals:

Is the minor currently authorized to work in the U.S.? 

 Yes 

 No

 No

URM Program Application • PAGE 13 OF 15

Section 4.6—Immigration Information
If the minor is a refugee, is a UNHCR BID report, BioData Form, Minor’s Questionnaire, and Anomaly Report (if applicable) attached to this application?   Not Applicable   Yes   No If no, please explain:

Does the minor have an attorney of record or an accredited representative?  Yes   No
If yes, please provide the name and contact information, if not the same as the assister information provided in
Section 1 of this application:

Is the minor currently receiving any other type of immigration support or services? 
If yes, please explain:

 Yes 

 No

Is there a pending immigration hearing relevant to this applicant?   Yes   No
If yes, please explain (provide date, type and city/state) and attach a copy of the hearing notice, if available:

URM Program Application • PAGE 14 OF 15

Section 4.7—Additional Comments or Information

URM Program Application • PAGE 15 OF 15

Please ensure the following documents are submitted to URMprogram@acf.hhs.gov with the
application. Multiple e-mail messages may be required.
 Page 1 with signatures, if not digitally signed (see Sections 1 and 2)
 Document(s) used to verify age and identity (see Section 3)
 Document, such as Notice to Appear, used to verify alien number if the minor is in ORR custody.
(see Section 3)
 Document(s) used to verify eligibility (see Section 3)
 Placement memo (if required in Section 4)
 Court order of legal responsibility (if required in Section 4.1)
 State or local hearing notice (if required in Section 4.1)
 Dependency or SIJ findings order (if required in Section 4.1)
 Home studies, third party recommendations, reunification denial letters and denied Release Request
Worksheets, if the minor is in ORR custody (see Section 4.2)
 Documentation referenced in Section 4.3, if applicable
 Incident reports (or SIRs, if applicable) (if required in Section 4.3)
 UC Assessment and Case Review (if required in Section 4.3)
 Documentation referenced in Section 4.4, if applicable
 Clinical assessment (if required in Section 4.4)
 UNHCR BID report, BioData Form, Minor’s Questionnaire, and Anomaly Report if the applicant is a refugee
(see Section 4.6)

SUBMIT

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