RR-06 Refusal of Temporary Assistance

OMB Control No:	0970-0474
Expiration Date:
Estimated Burden:	3 minutes

U.S. REPATRIATION PROGRAM
REFUSAL OF TEMPORARY ASSISTANCE

SECTION I: INTRODUCTION
The U.S. Repatriation Program provides temporary assistance to U.S. citizens and their dependents who have been returned by the Department of State from a foreign country to the United States because of destitution, illness, war, threat of war, invasion, or similar crisis; and who are without resources immediately accessible to meet their needs. The full cost for the temporary assistance provided must be repaid to the U.S. Government unless a waiver has been applied for and approved by the U.S. Department of Health and Human Services Office of Human Services Emergency Preparedness and Response.
SECTION II: REFUSAL OF U.S. REPATRIATION PROGRAM TEMPORARY ASSISTANCE
I understand the information I have received, verbally and in writing, about temporary assistance available under the U.S. Repatriation Program, and I decline assistance.
SECTION III: SIGNATURE
1. I am:  a Repatriate  an Authorized Representative (relationship to repatriate _______________________)
2. Name (Print)	3. Date of Birth (MM/DD/YYYY)	4. Country Returned From
5. Signature	6. Date (MM/DD/YYYY)
7. Witness (Print)	8. Date (MM/DD/YYYY)
9. Intake Person Notes:

PAPERWORK REDUCTION ACT OF 1995 (b. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to refuse temporary assistance under the U.S. Repatriation Program. Public reporting burden for this collection of information is estimated to average 0.05 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 voluntary (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.

Personal information provided on this form may only be disclosed for program purposes or under the conditions prescribed in 45 CFR 211.14 or 212.9.

GENERAL INFORMATION

Purpose: For individuals eligible for the U.S. Repatriation Program to opt out of receiving temporary assistance after receiving information about the U.S. Repatriation Program.

For intake person or service provider: Before obtaining the repatriate’s signature on this form, please verify that the signatory is an adult with sufficient level of literacy and language skills to understand this form. Persons with mental and physical conditions that may impede their understanding and/or completion of this form should not be required to sign it.

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.

Where to Submit: Return the signed copy to your repatriation case worker.

Disclosure: Voluntary

SPECIFIC INSTRUCTIONS

SECTION III: SIGNATURE

Item 1. Check the box according to who is filling out the form. If the repatriate refuses to fill out the form after refusing assistance, a case or intake worker should note this in Item 9.

Item 2. Name (Last, First, Middle). Print name formatted as last name, first name, and middle name.

Item 3. Date of Birth (MM/DD/YYYY). Enter date of birth for the eligible repatriate as two-digit day and month and four-digit year.

Item 4. Country Returned From. Provide the name of the primary country the eligible repatriate is returning from. This does not include airport layover countries.

Item 5. Signature. Repatriate’s signature to indicate they have been provided with information regarding the U.S. Repatriation Program and have chosen NOT to receive assistance from this Program.

Item 6. Date (MM/DD/YYYY). Enter the date as two-digit day and month and four-digit year.

Item 7. Witness (Print). Format the witness’s name as Last Name, First Name, Middle Initial. 

Item 8. Date (MM/DD/YYYY). Enter the date as two-digit day and month and four-digit year.

Item 9. Intake Person Notes. Include witness or case worker notes, if necessary.

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