R-2 Discharge Notification - UC Portal Version

OMB 0970-0552 [Valid through 02/28/2021]

UC Basic Information
First Name:
Last Name:

AKA:
Status:
Date of Birth:
A No.:
Age:
Country of Birth:

Gender:
LOS:
Current Program:
Admitted Date:
Discharge Notification

Date of Discharge:
Type Of Discharge:

Transfer

Sponsor DOB:

Time of Discharge:
Sponsor Name:
Relationship to UC:

Prove of Relationship:
ORR Decision:

Pending

Date of Decision:

Approve
Disapprove
Remanded, please provide info as detailed in
comments

Program Minor was Transferred to:

DHS Family Shelter:

Local Law Enforcement:
Specify, if Other is Selected:
Address:
City:
State:

Zip Code:

Phone:

Fax:

Legal Status of Minor:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to notify
stakeholders of the transfer of a UAC to another care provider facility or the release of a UAC from ORR custody. Public reporting burden for this collection of information is
estimated to average 0.12 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). 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.