1 Emergency Repatriation Eligibility Application

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

U.S. REPATRIATION PROGRAM
EMERGENCY REPATRIATION ELIGIBILITY APPLICATION

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to determine eligibility for temporary assistance under the U.S. Repatriation Program during an emergency repatriation. 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 obtain a benefit (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: ELIGIBILITY SELF-ASSESSMENT / VERIFICATION – TO BE COMPLETED BY APPLICANT

1. Answer the following questions.

Are you a U.S. citizen or a dependent of a U.S. citizen?

¨ Yes ¨ No

Do you lack resources to meet your immediate needs?

¨ Yes ¨ No

Did you return on an evacuation flight coordinated by the United States government due to destitution, illness, war, threat of war, or a similar crisis?

¨ Yes ¨ No

If yes to all, please continue to Section II.

SECTION II: APPLICANT INFORMATION – TO BE COMPLETED BY APPLICANT Include supporting documentation.

RESPONSIBLE PERSON INFORMATION

2. Date and Time Entered Emergency Repatriation Center

3. Are you a U.S. citizen? ¨ Yes – Skip Items 4 – 8, Continue to 9 ¨ No – Continue to Item 4

4. Are you applying on behalf of a U.S. citizen under the age of 18? ¨ Yes – Fill out Items 5 – 8 ¨ No – Skip Items 5 – 8, Continue to Item 9

5. Last Name

6. First Name

7. Middle Name

8. Relationship to Primary U.S. Citizen Applicant

PRIMARY U.S. CITIZEN APPLICANT INFORMATION

9. Last Name

10. First Name

11. Middle Name

12. Gender ¨ Male ¨ Female ¨ X

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

14. Social Security Number

15. Passport Number

16. Passport Issuing Country

17. U.S. Address (Street, City, State, Zip Code)

18. This address is: ¨ Permanent ¨ Temporary

19. Email Address

20. Phone Number

21. Airline and Flight Number

22. Final Destination (City, State)

23. Country Repatriated From

24. ERC Location (Airport / State)

SECTION III: ACCOMPANYING DEPENDENT(S) INFORMATION – TO BE COMPLETED BY APPLICANT Include supporting documentation.

25. Number of Family Members Travelling with You: Adults (Include Yourself ______) Minors (under 18) _______

26. Complete this information for each dependent. After completing this information, go to Part III.

27. DEPENDENT #1. If applicable, indicate if the dependent is a ¨ minor or ¨ incapacitated adult

Last Name

First Name

Middle Name

Date of Birth

Social Security Number

Citizenship

Identity Document Issuing Country _________________ ¨ Passport Number______________ ¨ ID Number ___________________

Gender ¨ Male ¨ Female ¨ X

Relationship to Primary U.S. Citizen Applicant

28. DEPENDENT #2. If applicable, indicate if the dependent is a ¨ minor or ¨ incapacitated adult

Last Name

First Name

Middle Name

Date of Birth

Social Security Number

Citizenship

Identity Document Issuing Country _________________ ¨ Passport Number______________ ¨ ID Number ___________________

Gender ¨ Male ¨ Female ¨ X

Relationship to Primary U.S. Citizen Applicant

29. DEPENDENT #3. If applicable, indicate if the dependent is a ¨ minor or ¨ incapacitated adult

Last Name

First Name

Middle Name

Date of Birth

Social Security Number

Citizenship

Identity Document Issuing Country _________________ ¨ Passport Number______________ ¨ ID Number ___________________

Gender ¨ Male ¨ Female ¨ X

Relationship to Primary U.S. Citizen Applicant

30. DEPENDENT #4. If applicable, indicate if the dependent is a ¨ minor or ¨ incapacitated adult

Last Name

First Name

Middle Name

Date of Birth

Social Security Number

Citizenship

Identity Document Issuing Country _________________ ¨ Passport Number______________ ¨ ID Number ___________________

Gender ¨ Male ¨ Female ¨ X

Relationship to Primary U.S. Citizen Applicant

31. DEPENDENT #5. If applicable, indicate if the dependent is a ¨ minor or ¨ incapacitated adult

Last Name

First Name

Middle Name

Date of Birth

Social Security Number

Citizenship

Identity Document Issuing Country _________________ ¨ Passport Number______________ ¨ ID Number ___________________

Gender ¨ Male ¨ Female ¨ X

Relationship to Primary U.S. Citizen Applicant

Comments

SECTION IV: NEXT OF KIN OR EMERGENCY CONTACT IN UNITED STATES – TO BE COMPLETED BY APPLICANT

32. Name (Last, First, M.I.)

33. Contact Information Telephone Email

34. Name (Last, First, M.I.)

35. Contact Information Telephone Email

SECTION V: NEEDS ASSESSMENT – TO BE COMPLETED BY EMERGENCY REPATRIATION CENTER (ERC) STAFF
36. Check here if no assistance is needed ¨
37. Assistance needed:
¨ Clothing	¨ Mental Health
¨ Immediate shelter (short-term hotel)	¨ General Information
¨ Housing	¨ Chaplain Assistance / Religious Service
¨ Financial Assistance	¨ Relocation Information
¨ Legal Services	¨ Translator
¨ Child Care	¨ Toiletries
¨ Locator Assistance for Other Family Members	¨ Medical
¨ Transportation to Final Destination	¨ Disability-related Needs
¨ Other (specify):	¨ Other (specify):
38. Referral to Caseworker at State of Final Destination: ¨ Yes ¨ No State / Territory: ____________________________
39. Additional Remarks

STOP HERE. BRING THIS FORM TO AN EMERGENCY REPATRIATION CENTER STAFF MEMBER TO BE COMPLETED.

SECTION VI: ELIGIBILITY DETERMINATION – TO BE COMPLETED BY ERC STAFF
39. Confirm the following about the applicant.
Is there a U.S. citizen or a dependent of a U.S. citizen in the nuclear family unit? If the applicant is not a U.S. citizen or a dependent of a U.S. citizen, please advise the person that he/she is not eligible for repatriation assistance.		¨ Yes ¨ No
Does the applicant(s) have resources (e.g., funds, transportation) immediately available to meet their needs?		¨ Yes ¨ No
Is the individual requesting temporary assistance through the U.S. Repatriation Program? If yes, explain the repatriation loan and obtain signature on Repatriation Repayment and Privacy Agreement.		¨ Yes ¨ No
Will the individual(s) require assistance at the final destination? If yes, ensure the state of final destination is noted in Section V, Question #37.		¨ Yes ¨ No
40. Ensure the following information is provided to the applicant:
Information about the U.S. Repatriation Program		¨ Yes ¨ No
Information on how to apply for a waiver and/or deferral of their loan		¨ Yes ¨ No
Information about repatriation assistance at final destination		¨ Yes ¨ No
41. Verify the following documentation has been collected from the applicant
Copy of the U.S. passport (biographical information only), or other proof of U.S. citizenship is attached to this form		¨ Yes ¨ No
Copy of passport/Identity documents for each dependent		¨ Yes ¨ No
Signed Repatriation Repayment and Privacy Agreement		¨ Yes ¨ No
42. Federal Approving Official (Print and Sign) Print Signature	43. Decision ¨ Approved ¨ Denied	44. Date (MM/DD/YYYY)
45. Comments

SECTION VII: REPATRIATION ASSISTANCE – TO BE COMPLETED BY ERC STAFF ERC staff should initial the appropriate service category line, and where applicable, indicate the amount of the service provided. Once all services have been arranged for the repatriate, keep the original form and provide a copy of this page to the repatriate. Include supporting documentation with application.

46. Temporary Assistance Provided. Fill out each row and calculate the cost for each type of assistance.

Services

Costs

Total

Lodging

# of Nights

# of Rooms

Nightly Rate in $

$____________

Confirmation #

Staff Initials

Applicant Initials

Cash Assistance

# of Persons Receiving Cards

# of Days

Total # of Cards

Card Value in $____ Fee $_____ Total Cost / Card $____

$____________

Last 4 Digits of Cash Card(s)

Staff Initials

Applicant Initials

Travel

Cost Per Ticket

# of Persons / Tickets

Additional Fees Per Ticket

$____________

Confirmation #

Staff Initials

Applicant Initials

Other. Please specify. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

$____________ $____________ $____________ $____________

ESTIMATED TOTAL COSTS

$

47. Notes / Updates. Any updates require initials of the applicant and intake staff and the date.

SECTION VIII: INTERPRETER

48: Was an interpreter used? ¨ Yes ¨ No

49. Interpreter’s Name and Affiliation

SECTION IX: SIGNATURE – TO BE COMPLETED BY REPATRIATE AFTER MEETING WITH ERC STAFF By signing below, I certify the information I provided on and in connection with this form is true and correct.

50. Print Name

51. Signature

52. Date (MM/DD/YYYY)

SECTION X: EXIT INFORMATION – TO BE COMPLETED BY ERC STAFF

53. Provided copies of this page and the signed Repatriation Repayment and Privacy Agreement to the repatriate

¨ Yes ¨ No

54. ERC Exit Time: _____:______ AM/PM

GENERAL INFORMATION

Purpose: This form is for U.S. citizens and their dependents to request temporary assistance from the U.S. Repatriation Program during an emergency repatriation incident.

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.

Intake staff at the emergency repatriation center (ERC) can assist with filling out the form.

When to Submit: U.S citizens and their dependents requesting assistance may apply at the ERC or within 90 days of arrival in the United States. This form should be filled out as soon as the applicant determines he or she needs temporary assistance prior to the end of the eligibility period.

Where to Submit: This form, and all supporting documents, should be provided to the ERC staff or the designated entity.

Disclaimer: Authorized staff from the Administration for Children and Families in the U.S. Department of Health and Human Services make all eligibility determinations.

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.”

SPECIFIC INSTRUCTIONS

SECTION I: ELIGIBILITY SELF-ASSESSMENT/ VERIFICATION

Item 1. Date and Time Entered ERC. Answer the questions by checking either the ‘Yes’ or ‘No’ boxes for each.

SECTION II: APPLICANT INFORMATION

Item 2. Date and Time Entered ERC. Provide the date and approximate time you entered the ERC.

Item 3. Are you a U.S. citizen? Indicate if you are a U.S. citizen by checking the corresponding ‘Yes’ or ‘No’ box. Check only one box. If you are a U.S. citizen, skip Items 4-8. If you are not a U.S. citizen, continue to Item 4.

Item 4. Are you applying on behalf of a U.S. citizen under the age of 18?

• If you are a U.S. citizen not applying on behalf of a U.S. citizen minor, check ‘No’ and skip Items 5-8 and go to Item 9.

• If you are not a U.S. citizen and are applying as the responsible person on behalf of a U.S. citizen under the age of 18, check ‘Yes’ and fill out Items 5-8.

• If you are neither a U.S. citizen or a dependent of a U.S. citizen, please do not complete the application and speak with an ERC staff member.

Item 5. Last Name. Enter the last name of the non-U.S. citizen responsible person.

Item 6. First Name. Enter the first name of the non-U.S. citizen responsible person.

Item 7. Middle Name. Enter the middle name of the non-U.S. citizen responsible person. If no middle name, enter “NMN.”

Item 8. Relationship to the Primary U.S. Citizen Applicant. Indicate the relationship of the responsible person filling out the form to the U.S. citizen applicant (example: parent, legal guardian.)

Item 9. Last Name. Enter the last name of the U.S. citizen applicant.

Item 10. First Name. Enter the first name of the U.S. citizen applicant.

Item 11. Middle Name. Enter the middle name of the U.S. citizen applicant. If no middle name, enter “NMN.”

Item 12. Gender. Mark the appropriate selection.

Item 13. Date of Birth (MM/DD/YYYY). Enter the U.S. citizen’s date of birth. Format as a two-digit month and date and four-digit year.

Item 14. Social Security Number. Enter the U.S. citizen’s social security number.

Item 15. Passport Number. Enter the U.S. citizen’s passport number.

Item 16. Issuing Country. Enter the issuing country of the U.S. citizen’s passport.

Item 17. U.S. Address (Street, City, State, Zip Code). Enter the primary U.S. address. Include apartment/unit number if applicable.

Item 18. This address is. Indicate if this address is temporary (under six months) or permanent (over six months).

Item 19. Email Address. Enter the primary email address to send communications regarding participation in the U.S. Repatriation Program.

Item 20. Phone Number. Enter the primary phone number to communicate with you regarding your (family’s) participation in the U.S. Repatriation Program.

Item 21. Airline and Flight Number. Enter the airline and flight number from the returning country to final U.S. destination. If it was a military-chartered flight, enter details, if possible.

Item 22. Final Destination (City, State). Enter the city and state of your (family’s) final destination (e.g., Raleigh, NC or Baltimore, MD.)

Item 23. Country Repatriated From. Enter the country repatriated from.

Item 24. ERC (Airport/ State). Enter the name of the airport and the state of the ERC you are located in.

SECTION III: ACCOMPANYING DEPENDENTS

Item 25. Number of Family Members Travelling with You. In the spaces provided indicate the number of adults, including yourself, and the number of minors included on this application.

Item 26. Complete this information for each dependent. Write on the back of this form if you need to include more than five (5) dependents.

Item 27. Dependent #1. Indicate if the dependent is a minor or incapacitated adult by checking the appropriate box. Enter the full name, DOB, SSN, citizenship, relationship to primary applicant, and the type and number of identity document in the spaces provided. Indicate if the dependent is a male, female, or X by checking the appropriate box.

Item 28. Dependent #2. See instructions for Item 27.

Item 29. Dependent #3. See instructions for Item 27.

Item 30. Dependent #4. See instructions for Item 27.

Item 31. Dependent #5. See instructions for Item 27.

SECTION IV: NEXT OF KIN OR EMERGENCY CONTACT IN U.S.

Item 32. Name (Last, First, Middle). Enter the name of an individual who will know how to get in touch with the repatriate(s) should the need arise.

Item 33. Contact Information. Enter the best contact information for the emergency contact.

Item 34. Name (Last, First, Middle). Enter the name of an individual who will know how to get in touch with the repatriate(s) should the need arise.

Item 35. Contact Information. Enter the best contact information for the emergency contact.

SECTION V: NEEDS ASSESSMENT

Item 36. Check here if no services are needed. If no services are needed, place an “X” in the box provided.

Item 37. Assistance Needed. If assistance is required, place an "X" in the box next to each service required.

Item 38. Referral to Caseworker at State of Final Destination. If it is anticipated that the repatriate (and their family) will need assistance at the state of final destination, place an “X” in the “Yes” box provided. If they will not require assistance at the state of final destination, place an “X” in the “No” box provided.

STOP HERE. BRING THIS FORM TO AN EMERGENCY REPATRIATION CENTER STAFF MEMBER TO BE COMPLETED.

SECTION VI: ELIGIBILITY DETERMINATION

Item 39. Confirm the following about the applicant. Place an “X” in the “Y” or “N” columns.

Item 40. Ensure the following information is provided to the applicant. Place an “X” in the “Y” or “N” columns.

Item 41. Verify the following documentation has been collected by the applicant. Place an “X” in the “Y” or “N” columns.

Item 42. Federal Approving Official (Print and Sign). Federal approving official will print and sign here.

Item 43. Decision. Federal approving official will indicate if the applicant is eligible or not by placing an “X” in either the “Approved” or “Denied” box.

Item 44. Date (MM/DD/YYYY). Federal approving official will indicate today’s date here.

Item 45. Comments. Include any comments, questions, or notes here, if applicable.

SECTION VII: REPATRIATION ASSISTANCE

Item 46. Temporary Assistance Provided. Provide details for each space provided for lodging, cash assistance, and travel. Indicate costs and total in U.S. dollar amounts. Once the table is completed and temporary assistance has been explained, agreed upon, and provided, the responsible adult/ U.S. citizen applicant and intake staff member must initial in the three boxes provided. Use the “Other” box to include any other temporary assistance provided that was not included in the table above. Include supporting documentation such as receipts and vouchers signed by the eligible repatriate.

Item 47. Notes/ Updates. If the responsible adult/ U.S. citizen applicant needs to make any adjustments to previously agreed upon temporary assistance, any updates must be included here. Include details, costs, date, and initials of both the intake staff member and responsible adult/ U.S. citizen applicant to confirm changes.

SECTION VIII: INTERPRETER

Item 48. Was an interpreter used? Place an “X” in the “Yes” or “No” box to indicate if an interpreter was used.

Item 49. Interpreter’s Name and Affiliation. If an interpreter was used, provide their full name.

PART IX: SIGNATURE.

Item 50. Print Name. The responsible person/ U.S. citizen applicant must print their name here after meeting with ERC staff, having their intake assessment, and receiving temporary assistance.

Item 51. Signature. The responsible person/ U.S. citizen applicant must sign here to certify the information provided on and in connection with this form is true and correct.

Item 52. Date (MM/DD/YYYY). Provide the date of signature. Format as a two-digit month and date and four-digit year.

SECTION X: EXIT INFORMATION

Item 53. Repatriate was provided with copies. Place an “X” in the “Y” or “N” columns.

Item 54. ERC Exit Time. Indicate the approximate time the repatriate(s) exited to ERC.

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