1 Emergency Repatriation Request for Cost Approval and Fed

OMB Control No:	0970-0474
Expiration Date:
Estimated Burden:	20 minutes

U.S. REPATRIATION PROGRAM
EMERGENCY REPATRIATION REQUEST FOR COST APPROVAL AND FEDERAL SUPPORT

SECTION I: AGENCY AND ASSISTANCE INFORMATION – TO BE COMPLETED BY AUTHORIZED OFFICIAL
1. Agency Name and Address	2. Requestor Name and Title				3. Incident Name and Date Started (MM/DD/YYYY)
4. Location(s) Where Service / Support is Needed			5. Date and Time of Request
6. Type of Request (only check one) ¨ Cost pre-approval; Estimated Amount $______________________ ¨ Federal support
7. Description of Assistance Requested (e.g., estimated cost, length of time, amount needed, etc.)
8. Justification of Request
9. Requestor Email Address				10. Requestor Phone Number
11. Requestor Signature				12. Date (MM/DD/YYYY)
SECTION II: FEDERAL DETERMINATION – TO BE COMPLETED BY AUTHORIZED FEDERAL STAFF
13. Date (MM/DD/YYYY) and Time Received		14. Federal Official Name
15a. Cost Pre-Approval Determination ¨ Approved ¨ Denied ¨ Partial _____________________________________ _______________________________________________ ¨ Need Additional Information ___________________ _______________________________________________		15b. Federal Support Determination ¨ Received ¨ Need Additional Information ___________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________
16. Authorized Federal Official Signature		17. Date (MM/DD/YYYY)

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to request pre-approval for costs or federal support for an emergency repatriation. Public reporting burden for this collection of information is estimated to average 0.3 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 cost approval or request federal support for an emergency repatriation (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 U.S. Repatriation Program, 330 C St. SW, Washington, D.C. 20201.

GENERAL INFORMATION

Purpose: This form is to request pre-approval for costs or federal support for an emergency repatriation incident.

Who Should Complete this Form: An official authorized by the state, territory, or authorized support organization.

When to Submit: Prior to incurring costs and as soon as support and/or need is identified.

Where to Submit: This form and any supporting documentation should be sent via e-mail to 1) the designated ACF staff member, and 2) OHSEPR-AF@acf.hhs.gov.

Disclosure: Voluntary

SPECIFIC INSTRUCTIONS

SECTION I: AGENCY AND ASSISTANCE INFORMATION – TO BE COMPLETED BY AUTHORIZED OFFICIAL

Item 1. Agency Name and Address. Provide the name of the requesting agency and the full address to include street, suite number (if applicable), city, state, and zip code.

Item 2. Requestor Name and Title. Provide the full name of the requesting point of contact and title.

Item 3. Incident Name and Date Started (MM/DD/YYYY). Enter the name of the incident (example: mission or exercise name) and the start date or anticipated start date. Format date as two-digit month and date and four-digit year.

Item 4. Location(s) Where Service/ Support is Needed. Enter the location where the incident or exercise is being conducted (example: military base, airport, etc.) Provide the address, to include city and state, and/or airport code.

Item 5. Time and Date of Request. Provide the date and time of submission.

Item 6. Type of Request. Check one of the two options provided. Indicate if the request is either for a cost pre-approval or for federal support.

Item 7. Description of Assistance Requested (e.g., estimated cost, length of time, amount needed, etc.). Provide a detailed description of the request and supporting documentation.

Item 8. Justification of Request. Provide a detailed justification and attach any supporting documentation.

Item 9. Requestor Email Address. Enter the primary email address to send communications regarding this request.

Item 10. Requestor Phone Number. Enter the primary phone number to reach the point of contact regarding this form.

Item 11. Requestor Signature. The requesting point of contact must sign here to process this form.

Item 12. Date (MM/DD/YYYY). Provide the date of submission using a two-digit month and day and four-digit year.

SECTION II: FEDERAL DETERMINATION – TO BE COMPLETED BY AUTHORIZED FEDERAL STAFF

Item 13. Date (MM/DD/YYYY) and Time Received. Provide the date and time form received.

Item 14. Federal Official Name. Enter federal official’s full name.

Item 15a. Cost Pre-Approval Determination. If request is cost pre-approval, select determination and provide information if needed.

Item 15b. Federal Support Determination. If request is for federal support, select determination and provide information if needed.

Item 16. Authorized ACF Official Signature. Federal Human Services Coordinating Official or authorized federal staff within OHSEPR.

Item 17. Date (MM/DD/YYYY). Provide the date of signature using a two-digit month and day and four-digit year.

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