Form 1 Withdrawal of Application or Declination of Placement Fo

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)
Date	Alien Number
First Name	Last Name
Requestor

WITHDRAWAL OF APPLICATION

To the Office of Refugee Resettlement:

My name is . I applied for the Unaccompanied Refugee Minors (URM) program on . I received an explanation of the program, its services, and my potential rights and responsibilities from on in (insert language) and understand the information that was presented to me. I hereby choose to withdraw my application to the URM program. I understand that by withdrawing my application for the URM program at this time, I may not be able to enter the program at a later date.

Signature of URM applicant Signature of witness

For interpreter (if applicable): I read this Withdrawal of Application in the URM Program form to

on ____, and he/she asserted that he/she understood the form and the consequences of withdrawing his/her application for the URM program at this time.

DECLINATION OF PLACEMENT

To the Office of Refugee Resettlement:

My name is . I applied for the Unaccompanied Refugee Minors (URM) program on . I received an explanation of the program, its services, and my potential rights and responsibilities from on

in (insert 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 be able to enter the program at a later date.

Signature of URM applicant Signature of witness

For interpreter (if applicable): I read this Declination of Placement in the URM Program form to on

, and he/she asserted that he/she understood the form and the consequences of withdrawing his/her application for the URM program at this time.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide written notice that an unaccompanied minor is no longer interested in participating in the Unaccompanied Refugee Minors Program. Public reporting burden for this collection of information is estimated to average .20 hour per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. 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.