1 Loan Waiver and Deferral Application

OMB Control No:	0970-0474
Expiration Date:
Estimated Burden:	30 minutes

U.S. REPATRIATION PROGRAM
LOAN WAIVER AND DEFERRAL APPLICATION

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to request a loan waiver or deferral of payment for temporary assistance received under the U.S. Repatriation Program. Public reporting burden for this collection of information is estimated to average 0.5 hours per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to apply for a waiver or deferral (42 U.S.C. Section 1313). 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 0970-0474 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact the U.S. Repatriation Program, 330 C St. SW, Washington, D.C. 20201.

SECTION I: REPATRIATE INFORMATION

1. I am requesting (select one): ¨ Waiver ¨ Deferral

2. Last Name

3. First Name

4. Middle Name

5. Date of Birth (MM/DD/YYYY)

6. Social Security Number

7. Address (Street, City, State, Zip Code)

8. Type of Housing ¨ Temporary ¨ Permanent

9. Name of Shelter, if Applicable

10. Phone Number

11. Email Address

12. Complete the table below for each individual included in the repatriation case.

Last Name

First Name

Date of Birth

Relationship

SECTION II: PUBLIC ASSISTANCE

13. Complete the table below for yourself and members of your household if you are receiving and/or are expected to receive public assistance. Use a separate sheet of paper if necessary. Provide supporting documentation of applications.

Last Name

First Name

Type of Assistance Applied For

Date Application was Submitted

Application Status: Pending, Denied, Other

Date Application was Accepted

Amount Receiving or Expected to Receive

Total Amount of Public Assistance Receiving or Expected to Receive

SECTION III: REPATRIATE OR LEGAL GUARDIAN EMPLOYMENT AND INCOME INFORMATION Provide supporting documentation of employment and income.

14. Are you able to work? ¨ Yes: Complete information below. ¨ No: Provide a written explanation or documentation as applicable.

15. Primary Occupation

16. Duration of time at present employer MM/YYYY to MM/YYYY

17. Present Employer’s Name

18. Employer’s Contact Information Phone Number Email

19. Address (Street, City, State, Zip Code)

20. Other Employment

Employer’s Name

Address

Phone Number

Email Address

21. Monthly Income of All Household Members

Last Name

First Name

Salary or Wages (Total in Dollars)

Type of Income Received (e.g., child support, SSI, etc.)

Other Income

22. Present Monthly Combined Household Income Salary or Wages $ _____ Other (assistance) $ _____ Total: $ ___________

SECTION IV: ASSETS Provide supporting documentation.

23. Assets

Total Amount in Dollars

In Your Possession or Expected to Receive

Checking Accounts

Savings Accounts

Debts Owed to You

Judgements Owed to You

Stocks, Bonds, and other Securities

Personal Property in Excess of $1,500

Other: Please Specify

Total

SECTION V: EXPENSES AND LIABILITIES Provide supporting documentation.
24. Fixed Monthly Expenses	Monthly Payment
Rent
Utilities
Food
Transportation (e.g., public or ride-share)
Household
Lawyer / Legal Expenses
Insurance
Medical Costs
Total
25. Loans and Liabilities	Monthly Payment		Total Amount Currently Owed
Mortgage (if different from rent)
Car
Lawyer/ Legal Expenses
Furniture
Taxes Owed
Loans Payable (to banks, finance company, etc.)
Credit Card(s)
Child Support
Other Loans and Debt
Other Loans and Debt
Total
SECTION VI: ADDITIONAL QUESTIONS
26. Answer each question by checking the Yes or No selection.
Are you a part of any pending lawsuit?		¨ Yes ¨ No
Do you have any claims from which you expect to receive any income or resources?		¨ Yes ¨ No
Do you have any claims against any individual, trust or state, partnership, corporation, or government?		¨ Yes ¨ No
Are you a trustee, executor, or administrator of any estate?		¨ Yes ¨ No
Is anyone holding money on your behalf?		¨ Yes ¨ No
Will you receive or inherit any financial assets within the next two years?		¨ Yes ¨ No
Do you receive or expect to receive benefits from any established trust, claim for compensation or damages, contingent on future interest in property of any kind?		¨ Yes ¨ No
Do you receive or expect to receive federal, state, or local cash payment or refund?		¨ Yes ¨ No
27. Provide an explanation below to all YES answers in Part VI. Include supporting documentation with application.

SECTION VII: SIGNATURE By signing this document, I certify that it is true, complete and accurate to the best of my knowledge. I am aware that any false, fictious, or fraudulent information may subject me to criminal, civil or administrative penalties. (US. Code, Title 18, section 1001)
28. Print Name of Applicant (Last, First, Middle)
29. Signature of Applicant or Representative/ Legal Guardian		30. Date (DD/MM/YYYY)
SECTION VIII: AUTHORIZED REPRESENTATIVE INFORMATION (IF APPLICABLE)
31. Representative Last Name	32. Representative First Name	33. Representative Middle Name
34. Relationship	35. Phone Number	36. Email Address

GENERAL INFORMATION

Purpose: Individuals who received temporary assistance through the U.S. Repatriation Program should use this form to request a loan waiver or deferral of payment.

Who Should Sign this Form: This form can be completed and signed by:

• Repatriate on behalf of themselves and dependents;

• Adult representative of a minor child (parent, guardian, or legal representative); or

• Adult representative of a mentally or physically impaired adult.

What to Include: The application must contain necessary supporting documentation. If the application is missing documentation, your waiver or deferral request may be denied.

When to Submit: Requests should be submitted as soon as the need for a waiver or deferral is identified.

Where to Send: This form, and all supporting documents, should be provided to ISS-USA, 1120 N. Charles St., Suite 300, Baltimore, MD 21201.

Disclaimer: Title 18 of the United States Code 1001 states that an individual who “knowingly and willfully - (1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; (2) makes any materially false, fictitious, or fraudulent statement or representation; or (3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry; shall be fined under this title, imprisoned not more than 5 years…or both.”

The U.S. Repatriation Program may grant a deferral instead of a waiver based on the application and supporting documentation.

All loan waiver and deferral determinations are made by the Office of Human Services Emergency Preparedness and Response (OHSEPR) in accordance to 45 CFR 211.13 and 212.7.

DO NOT complete this form if you are looking for a payment plan. For inquiries related to your loan collection and payment plan, please contact the HHS-Program Support Center at: Accounting Services – Debt Collection Center, 7700 Wisconsin Avenue, Suite 8310-A, Bethesda, Maryland 20857. Email: PSCDebtServicing@psc.hhs.gov / Telephone: 301-492-4664.

SPECIFIC INSTRUCTIONS

SECTION I: ADULT REPRESENTATIVE INFORMATION

Item 1. I am requesting (select one). Indicate if you are requesting a ‘waiver’ or ‘deferral’ by placing an ‘X’ in the applicable box.

Item 2. Last Name. Provide your last name.

Item 3. First Name. Provide your first name.

Item 4. Middle Name. Provide your middle name. If no middle name, write “NMN.”

Item 5. Date of Birth (MM/DD/YYYY). Provide your date of birth. Format as a two-digit month and date and four-digit year.

Item 6. Social Security Number. Provide your social security number.

Item 7. Address (Street, City, State, Zip Code). Provide your primary U.S. address. Include apartment/unit number if applicable.

Item 8. Type of Housing. Indicate if the address in Item 6 is ‘Temporary’ (you will be there less than six months) or ‘Permanent’ (you will be there longer than six months) by placing an ‘X’ in the applicable box.

Item 9. Name of Shelter, if Applicable. If the residence is a shelter, provide the name. If this does not apply, write “N/A.”

Item 10. Phone Number. Enter the primary phone number to communicate with you regarding your (family’s) participation in the U.S. Repatriation Program.

Item 11. Email Address. Enter the primary email address to send communications regarding participation in the U.S. Repatriation Program.

Item 12. Complete the table below for each individual included on the repatriation loan. If more than 5, use another sheet of paper. Provide the first and last name, date of birth (MM/DD/YYYY), and relationship for each individual.

SECTION II: PUBLIC ASSISTANCE

Item 13. Complete the table below for yourself and members of your household. For each member of your household receiving government assistance, fill out a row and place an ‘X’ in each applicable column. Populate the total in the bottom row where indicated. Providing supporting documentation to include application information and proof of benefit amount.

SECTION III: REPATRIATE OR LEGAL GUARDIAN EMPLOYMENT AND INCOME INFORMATION.

Item 14. Are you able to work? Place an ‘X’ in one of the two boxes provided. If ‘Yes’ complete boxes 15-20. If ‘No’ provide an explanation in the space provided in the box.

Item 15. Primary Occupation. Enter your primary occupation.

Item 16. Duration of Time at Present Employer. Populate the time in months, starting from the start date to end date. If currently employed, write the start date to ‘present.’

Item 17. Present Employer’s Name. Enter the name of your employer/ company/ business name.

Item 18. Phone Number / Email. Provide the best contact information for your present employer.

Item 19. Address (Street, City, State, Zip Code). Provide the street, suite number (if appliable), city, state and zip code of your present employer.

Item 20. Other Employment. If you have more than one primary occupation, list out applicable information in the table provided. Provide supporting documentation to include paystubs.

Item 21. Monthly Household Income. For each member of your household generating an income, fill out a row and provide details for each column.

Item 22. Present Monthly Combined Household Income. Combine your income and members of your household’s income in the space provided.

SECTION IV: ASSETS

Item 23. Assets. Fil out each row of the table and indicate the amount and if the amount is in your possession or if you expect to receive at a later date. Include the approximate month and year if it is to be received at a later date. If the row does not apply, write ‘N/A’ in the ‘Total Amount in Dollars’ column. Provide supporting documentation such as bank statements.

SECTION V: FIXED MONTHLY EXPENSES AND LIABILITIES

Item 24. Fixed Monthly Expenses. Provide the monthly payment and total balance due in the spaces provided for each row. Provide a total in the last row. Include supporting documentation such as rental agreements, insurance information, etc.

Item 25. Loans and Liabilities. Provide the monthly payment amount and total amount for the items listed. Provide a total in the last row.

SECTION VI: ADDITIONAL QUESTIONS

Item 26. Answer each question. Answer each question, A- H, by checking the Yes or No selection.

Item 27. Provide an explanation below to all YES answers in Part VI. Use additional pages, if necessary.

SECTION VII: SIGNATURE

Item 28. Print Name of Applicant (Last, First, Middle). Provide the full name of the applicant.

Item 29. Signature of Applicant or Representative/ Legal Guardian. Sign in the space provided.

Item 30. Date (MM/DD/YYYY). Provide the date of signature.

SECTION VII: AUTHORIZED REPRESENTATIVE INFORMATION (IF APPLICABLE)

Item 31. Representative Last Name. Provide the representative’s last name.

Item 32. Representative First Name. Provide the representative’s first name.

Item 33. Representative Middle Name. Provide the representative’s middle name. If no middle name, write “NMN.”

Item 34. Relationship. Indicate the relationship of the representative to the repatriate.

Item 35. Phone Number. Provide the representative’s phone number.

Item 36. Email address. Provide the representative’s email address.

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