Form S-5 Sponsor Assessment

OMB 0970-#### [Valid through MM/DD/2020]

OFFICE OF REFUGEE RESETTLEMENT

SPONSOR ASSESSMENT

UAC Basic Information
First Name:	     				Status:				ADMITTED
Last Name:	     				AKA:				     
Date of Birth:	     				Gender:
A #:	     				LOS:				     
Age:	  				Current Program:				     
Country of Birth:	     				Admitted Date:				     
Sponsor Basic Information
First Name:	     				AKA:				     
Last Name:	     				A #:				     
Date of Birth:	     				Country of Birth:				     
Age:	  				Country of Residency:				     
Gender:					Primary Sponsor:				Yes No
Sponsor Cultural Information
Use this section to document the sponsor’s linguistic and cultural background, including cultural, social, and communal norms and practices for the care of children.
Primary Language Spoken:		     			Religious Affiliation:		     
Other Languages Spoken:		     
Additional cultural information:		     
Family Relationships
Use this section to document the sponsor’s familial and other significant relationships in country of origin and in the U.S. A genogram (family tree) may be used as a tool to answer these questions and is required for distant relative Cat 3 potential sponsors.
Genogram completed? (Required for distant relative Cat 3 sponsors)				Yes No
Family in Country of Origin
Do you have family in your home country? (If yes, describe below)				Yes No
Additional information on family in country of origin:				     
Family and Family Friends in the U.S.
Do you have family or family friend in the U.S.? (If yes, list below)				Yes No
Name			Age			DOB		Gender		Relationship to Sponsor

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Do you have any relatives who are also in ORR care?			Yes No
If yes, do you know where they are?			     
Additional information on family and family friends in the U.S.:			     
Spouse/Partner
Do you have a partner? (if yes, answer below questions)			Yes No
What is your partner’s name and age?			     
Do you live with your partner?			Yes No
If no, where does your partner live?			     
Are you married to your partner?			Yes No
Are you legally married or is the relationship a partnership or cohabitation?			     
What is your relationship like with your spouse?			     
Have you ever been involved in a Dissolution of Marriage case?			Yes No
If yes, explain:			     
Additional information on the sponsor’s partner:			     
Children
Do you have any children (If yes, list below)			Yes No
Name	Age	DOB		Gender	Current Location	Name of Mother/Father

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Did any of your children come to the U.S. with you? (If not born in U.S.)				Yes No
Do you have any children living in your home country?				Yes No
Have any of your children ever been in ORR care?				Yes No
Who is caring for your children?				     
Additional information on the sponsor’s children:				     
How do you discipline your children and how do you plan to discipline the minor?				     
Have you or your spouse/partner ever had Child Protective Services involvement?				Yes No
If yes, explain:				     
Have you ever been involved in a child support case?				Yes No
If yes, explain:				     
Do you provide court ordered financial support to your children?				Yes No
If yes, explain:				     
Have you ever had a child removed from your custody?				Yes No
If yes, why? (Obtain documentation)				     
Have any of your household members ever had a child removed from his/her custody?				Yes No
If yes, why? (Obtain documentation)				     
Household Composition
Use this section to document the sponsor’s household composition, including the sponsor’s knowledge of any household members who may have a serious, contagious disease; or criminal convictions or charges.
Does anyone else live in your home? (If yes, list below)					Yes No
Name	Age	DOB	Gender		Phone Number	Valid Identity Document Received	Relationship to Sponsor	Employed	Dependent on Sponsor Income	Background Checks

     	  	Click here to enter a date.		     	☐Yes ☐No		☐Yes ☐No	☐Yes ☐No
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     	  	Click here to enter a date.		     	☐Yes ☐No		☐Yes ☐No	☐Yes ☐No

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Describe your home:				     
Describe where the minor will sleep:				     
How do you expect the UAC to contribute to your household?				     
Does anyone in the household have a serious, contagious disease?				Yes No
If yes, explain:				     
Do any of the occupants have criminal convictions or charges, other than minor traffic violations?				Yes No
If yes, explain:				     
Previous Sponsorship
Use this section to document if the sponsor and/or the sponsor’s household members have ever sponsored or attempted to sponsor another child. If the sponsor and/or the sponsor’s household members did sponsor or attempt to sponsor a child, document the status of the child’s safety and well-being.
Sponsor
Have you ever attempted to sponsor another child that is/was in ORR care? (If yes, list below and answer the following questions)						Yes No
Name	A No.	DOB	Gender		Sponsor’s Relationship to UAC		Current Location	ORR Release Decision	Date of Discharge	Discharge Program Name

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ADD OR DELETE ROWS AS NEEDED (you will need to copy dropdowns, date fields, etc. into your new row)
Have you ever attempted to sponsor a child from ORR, but decided to withdraw your application?			Yes No
If yes, then why did you withdraw?			     
Have you ever been denied sponsorship by ORR?			Yes No
If yes, then why did ORR deny your sponsorship application?			     
How many children did you sponsor?			     
Is the child still residing with you?			Yes No
If no, explain:			     
Did you undergo a home study?			Yes No
If yes, why?			     
Is/has the child received Post Release Services?			Yes No
Is the child enrolled in or attending school?			Yes No
When is the child’s upcoming court date?			     
Did you attend an LOPC presentation?			Yes No
Describe the UAC’s current safety and well-being since release from ORR care to the sponsor:				     
Household Members
Have any of your household members attempted to sponsor another child that is/was in ORR care? (If yes, list below and answer the following questions)							Yes No
Name	A No.	DOB		Gender	Sponsor’s Relationship to UAC	Current Location		ORR Release Decision	Date of Discharge	Discharge Program Name

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Did he/she ever attempted to sponsor a child from ORR, but decided to withdraw your application?		Yes No
If yes, then why did he/she withdraw?		     
Has he/she ever been denied sponsorship by ORR?		Yes No
If yes, then why did ORR deny his/her sponsorship application?		     
How many children did he/she sponsor?		     
Is the child still residing with him/her?		Yes No
If no, explain:		     
Did he/she undergo a home study?		Yes No
If yes, why?		     
Is/has the child received Post Release Services?		Yes No
Is the child enrolled in or attending school?		Yes No
When is the child’s upcoming court date?		     
Did he/she attend an LOPC presentation?		Yes No
Describe the UAC’s current safety and well-being since release from ORR care to the sponsor:		     
Proof of Identify
Use this section to document information and documents provided by the sponsor to establish the sponsor’s identity and confirm that the sponsor’s identity was verified. If the sponsor’s identity was unable to be verified, provide an explanation under the “Additional information on identity” section below.
Sponsor
Sponsor’s identity is verified:	Yes No
List proof of identity documents provided:
Identity Document Type			Expiration Date (if applicable)	Document Verified by Government Agency	Picture ID

	Click here to enter a date.	☐Yes ☐No	☐Yes ☐No
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Household Members
Household Members’ identity is verified:		Yes No
List proof of identity documents provided:
Household Member Name	Identity Document Type		Expiration Date (if applicable)	Document Verified by Government Agency	Picture ID

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Adult Caregivers
Adult Caregiver’s identity is verified:		Yes No
List proof of identity documents provided:
Adult Caregiver Name	Identity Document Type		Expiration Date (if applicable)	Document Verified by Government Agency	Picture ID

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Additional information on identity:

     

PROOF OF IMMIGRATION STATUS OR U.S. CITIZENSHIP

Sponsor Legal Status:

Sponsor’s legal status verified with non-expired document(s):

Yes No

List proof of immigration status or U.S. citizenship document(s) provided:

     

Proof of Relationship

Use this section to document information and documents provided by the sponsor to establish the sponsor’s relationship to the UAC and to confirm that the relationship was verified. If the sponsor’s relationship to the UAC was unable to be verified, provide an explanation under the “Explain how the sponsor is related to or knows the UAC and/or the UAC’s family” section below.

Sponsor’s Relationship to UAC:

Sponsor Category:

Sponsor’s Relationship to UAC is Verified:

Yes No

List proof of relationship documents provided:

Relationship Document Type

Expiration Date (if applicable)

Date Document Issued (if applicable)

Verified by Government Agency or Consulate

Picture ID

	Click here to enter a date.	Click here to enter a date.	☐Yes ☐No	☐Yes ☐No
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Explain how the sponsor is related to or knows the UAC and/or the UAC’s family:			     
Proof of Address
Use this section to document information and documents provided by the sponsor to establish that the sponsor lives at the address he/she reported to ORR and that the reported address is a residence. If the sponsor’s address was unable to be verified, provide an explanation under the “Additional proof of address information” section below.
What is your current address and contact information? (enter below)
Address:	     			Home Phone:			     
City:	     			Email:			     
State:	  			Work Phone:			     
Zip Code:	     			Fax:			     
How long have you lived at the current address?		     
Describe the area/neighborhood where you reside?		     
Do you receive your mail at a different address?		Yes No
If yes, what is the address that you use to receive mail?		     
Was address where the sponsor currently resides verified as a residence on Google Maps?					Yes No
Was address where the sponsor currently resides verified as a residence on Google Earth?					Yes No
Was address where the sponsor currently resides verified as a residence on Smarty Streets?					Yes No
List proof of address documents provided:
Address Document Type						Date Document Issued (if applicable)

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Where else have you lived in the U.S.?
Address	City	State	Zip Code	Date Range Resided at Address	Resided at Address Within Past 5 Years

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ADD OR DELETE ROWS AS NEEDED (you will need to copy dropdowns, date fields, etc. into your new row)

Additional proof of address information:

     

Proof of Stability

Discusses with the sponsor, his/her ability to support and financially provide for the minor while in their care.

Does the sponsor have a job? (If yes, answer the following questions)

Yes No

Name of Employer:

     

Location of Employment:

     

Length of Time at present employer:

     

Income:

     

Work Hours/Schedule:

     

Does the sponsor have financial needs?

Yes No

If yes, explain:

     

Does the sponsor have adequate housing?

Yes No

If yes, explain:

     

Sponsor Care Plan

Use this section to document that the sponsor’s plan to care for the minor adequately addresses the care, supervision, safety, education, and resources required to meet the UAC’s needs.

Care Plan

Tell me about your plans to address the UAC’s educational needs:

     

What school will the minor attend?

     

Does the sponsor know the school enrollment process?

Yes No

Who will transport the UAC to and from school?

     

Who will supervise the UAC before and after school?

     

Does the minor have any medical conditions that will need treatment that you are aware of?

     

Tell me about your plans to address the UAC’s health care needs (If the UAC is pregnant or with child, also address the health care plans for the UAC’s child).

     

Tell me about your plans to address the UAC’s mental health care and counseling needs.

     

What are the medical services in your area?

     

What are the counseling services in your area?

     

Tell me about the types of community resources and services that you plan to access to address the UAC’s needs.

     

Is the potential sponsor familiar with community resources and services in the area? (Case Manager assists sponsor in identifying community service providers and programs and encourages sponsor to participate in applicable services such as parenting, gang prevention, substance abuse psycho-education in preparation for UAC’s release)

Yes No

Does the minor have any criminal history or behavior issues that you are aware of?

     

Is there anything that would prevent the sponsor from enrolling in supportive services for the UAC’s needs?

Yes No

Did the sponsor watch the Sponsor Video?

Yes No

Did the sponsor read the Sponsor Handbook?

Yes No

Will you accept assistance from Post-Release Service providers? (if applicable)

Yes No

Safety Plan

Explain how you plan to ensure the safety of the minor:

     

Supervision Plan

Does the sponsor have family or friends nearby that will be helping in caring for the minor? (If yes, list the individual(s))

Yes No

Name

SSN/A No.

Age

DOB

Gender

Home Address

Phone Number

Relationship to Sponsor

Background Checks

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Explain how you plan to supervise the minor:		     
Alternate Adult Caregiver Plan
Is the sponsor a U.S. citizen or a lawful permanent resident?					Yes No
If no, list the adult caregiver identified who will assume responsibility for the child if sponsor becomes unavailable to care for the minor.
Name	SSN/A No.		Age	DOB		Gender	Home Address	Phone Number	Relationship to Sponsor	Background Checks

     

     

  

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Criminal History
Use this section to document the sponsor’s self-disclosures of any criminal charges, sexual offenses or child abuse/neglect charges or arrests.
Any criminal history? (If yes, list below)		Yes No
List any felony convictions:		     
List any misdemeanor convictions:		     
List any probation/parole:		     
List and describe any disclosed criminal activity:		     
List any child abuse and neglect history:		     
History of Incarceration or Detention
Crime	Date		Length of Sentence/Detainment	Location

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ADD OR DELETE ROWS AS NEEDED (you will need to copy dropdowns, date fields, etc. into your new row)
Additional information on criminal history:		     
UAC Journey and Apprehension
Use this section to document if the UAC journeyed to the U.S. to live with this sponsor and to assess if the potential sponsor had a role in coordinating or financing the journey. Also, this section will help assess how much the potential sponsor knows about the UAC’s journey, which should be compared against the UAC Assessment responses.
Describe the UAC’s day to day life in home country:			     
Do you know why the UAC decided to travel to the U.S. at this time?			     
Did the potential sponsor mention any U.S. immigration policy or practice as a factor in the UAC’s decision to travel to the U.S.?			Yes No
Did the potential sponsor mention economic, job, or educational opportunities as a factor in the UAC’s decision to travel to the U.S.?			Yes No
When did the UAC leave his/her home country (month, day, and year)?			     
How long did the trip take?			     
Who paid for the UAC’s trip to the U.S.?			     
How did the UAC get to the U.S.?			     
Where was the UAC planning on living in the U.S. and with whom?			     
Do you know if the UAC has ever been to the U.S. before?			Yes No
If yes, when?			     
Human Trafficking
Use this section to document any trafficking concerns in the sponsor’s country of origin and in the U.S. and to determine if additional services or referrals are needed. It should be explained to the sponsor that this information is not for immigration purposes, but to have a better understanding of his/her journey and any challenges they may have faced during this time.
Sponsor’s Journey to the U.S. (if applicable)
Use this section to document information regarding the sponsor’s journey from their country of origin will be gathered here.
When and why did you first decide to travel to the U.S.?				     
Who planned/organized your journey?				     
Did the arrangements change during the journey?				Yes No
If yes, how?				     
Did anyone pay for your travel to the U.S.?				Yes No
Does that person need to be paid back?				Yes No
Is there a plan for that person to be paid back?				Yes No N/A
What do you believe will happen if that person if not paid back?				     
Does your family or a family friend owe money to anyone for the journey?				Yes No
If yes, how much?				     
Did you ever have to depend upon non family members to provide basic needs such as clothes, food, and housing?				Yes No
Did you experience any challenges, trauma, or abuse by family in home country?				Yes No
Where did you first live in the U.S. and with whom?				     
Have you traveled back to your country of origin since your arrival to the U.S.?				     
Additional information on sponsor’s journey to the U.S.:				     
Coercion Indicators
Use this section to assess for indicators of trafficking by force, fraud, or coercion in the sponsor’s country of origin, during the sponsor’s journey, and in the U.S. This includes any pressure, threats, deception, or harm experienced by the sponsor or the sponsor’s family members.
Did anyone threaten you or your family?				Yes No
If yes, explain:				     
Were you ever physically harmed?				Yes No
If yes, explain:				     
Was anyone around you ever physically harmed?				Yes No
If yes, explain:				     
Were you ever held against your will?				Yes No
If yes, explain:				     
Did anything bad happen to anyone else in this situation or anyone else who tried to leave?				Yes No
If yes, explain:				     
Did anyone ever keep/destroy your documents?				Yes No
If yes, explain:				     
Did anyone ever threaten to report you to the police/immigration?				Yes No
If yes, explain:				     
Are you worried anyone might be trying to find you?				Yes No
If yes, explain:				     
Additional information on coercion indicators:				     
Debt Bondage/Labor Trafficking Indicators
Use this section to assess for indicators of debt bondage and labor trafficking in the sponsor’s country of origin, during the sponsor’s journey, and in the U.S. This includes any information regarding contracts, commitments, arrangements, or debt the sponsor is aware of or responsible for repaying and whether the sponsor felt unsafe or scared in their working environment.
Did you perform any work or provide any services?				Yes No
Who arranged the work?				     
What type of work did you perform and where?				     
How often did you have to work?				     
Did work conditions change over time?				     
Is there a debt?				Yes No
What is the amount of the debt?				     
Has the debt amount ever increased?				Yes No
By how much?				     
When did it increase?				     
Why did it increase?				     
Have you or your family ever been threatened over payment or work for the journey?				Yes No
If yes, who threatened you and how?				     
What did you think would happen if you left the job or stopped working?				     
Were you ever made to work or do anything you did not want to do?				Yes No
If yes, explain:				     
Did you receive pay or did someone else keep the pay?				     
Were you paid what was promised when you started working and were those promises kept?				     
Were expenses taken out of the pay?				Yes No
If yes, what expenses?				     
How did you get to the work site?				     
Where did you live while working?				     
Was your freedom of movement ever restricted or closely monitored?				     
Were you ever restricted from communicating or socializing with others, not allowed to speak for yourself, told what to say, or isolated from others?				     
Did anyone arrange for you to work after arriving in the U.S.?				     
If yes, explain:				     
Additional information on debt bondage/labor trafficking indicators:				     
TVPRA
Use this section to document whether the case requires a TVPRA-mandated home study based information gathered in this assessment and from any other relevant sources.
Based on the sponsor assessment, does the sponsor present signs of being abused, maltreated, exploited, or trafficked?				Yes No
If yes, provide a short summary:				     
Referred to OTIP?				Yes No
Based on the sponsor assessment, does the sponsor clearly present a risk of abuse, maltreatment, exploitation, or trafficking to the UAC? If “Yes” is checked, the case must be referred for a mandatory home study.				Yes No
If yes, provide a short summary:				     
Fraud
Use this section to document if any individual or entity has attempted to defraud the sponsor in relation to the ORR reunification process.
Have you ever been contacted and asked to pay fees/money related to the release of the minor?			Yes No
If yes, explain:			     
Have you ever been contacted and asked to pay fees/money related to the release of a minor you previously sponsored or attempted to sponsor and not reported it to ORR?			Yes No
If yes, explain:			     
Additional Information
Use this section to report any additional information that may be pertinent to the sponsor’s assessment that has not been covered in the sections above or that require further elaboration.
     
Case Manger’s Assessment of Sponsor and Concluding Remarks
Use this section to provide a thorough assessment of the sponsor’s ability to safely care for the UAC, provide for the UAC’s individual needs, and ensure the safety and well-being of the UAC.
     
Certification
Signature:				Title:	     
Print Name:	     			Date:	     

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to document the suitability assessment of a potential sponsor to provide for the safety and well-being of a UAC. Public reporting burden for this collection of information is estimated to average 1.0 hours per response, 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 (Homeland Security Act, 6 U.S.C. 279, and Trafficking Victims Protection Reauthorization Act, 8 U.S.C. 1232). 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. If you have any comments on this collection of information please contact UACPolicy@acf.hhs.gov.