Form LRG-4 Form LRG-4 Acknowledgement of Receipt of Legal Resource Guide

OMB 0970-0565 [valid through MM/DD/YYYY]

Administration for Children & Families
Office of Refugee Resettlement

Acknowledgment of Receipt of Legal Resource Guide
Care Provider Instructions
Care providers must provide a copy of the Legal Resource Guide to children in their care at admission
(including after initial placement and after transfer from another care provider) and upon discharge from ORR
custody. Care providers must also explain the contents of the Legal Resource Guide to children in their
preferred language and in a manner that is appropriate for the age and culture of the child (see UC Policy
Guide Section 3.2.2 Orientation).


The Legal Resource Guide contains the following documents:


•
•
•

Notice of Rights and Procedures

ImportaMi 

Immigration Court Locations 


Each time the child is provided a copy of the Legal Resource Guide, the care provider must have the child sign
this form confirming receipt of the documents (Page 2 at admission and Page 3 upon discharge). Care provider
staff must also sign as a witness. If the child is unable to sign (e.g., child is preliterate), the care provider marks
an “X” in the signature line and provides an explanation in the related text field. All fully completed and signed
copies of Page 2 and Page 3 of this form must be uploaded under the UC Documents section of the child's
case file in UC Portal.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to
obtain acknowledgement from unaccompanied children upon admission and upon discharge from ORR custody that they received certain
legal resource materials from ORR. Public reporting burden for this collection of information is estimated to average 0.25 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
UCPolicy@acf.hhs.gov.
LRG-4 (ENG) | Version 5
Revised MM/DD/20YY

Page 1 of 3

Acknowledgment of Receipt of Legal Resource Guide

Office of Refugee Resettlement

Provision of Legal Resource Guide Upon Admission
Upon admission to the care provider program, I received copies of the following documents:
Notice of Rights and Procedures

ImportaMi 

Immigration Court Locations 


Child Signature

Child Name

Date

Care Provider Staff/Witness Signature

Care Provider Staff/Witness Name and Title

Date

Care Provider Program Name

If the child is unable to sign, mark an “X” in the signature line and provide an explanation below.
Reason child is unable to sign (if applicable)

LRG-5 (ENG) | Version 5
Revised MM/DD/20YY

Page 2 of 3

Acknowledgment of Receipt of Legal Resource Guide

Office of Refugee Resettlement

Provision of Legal Resource Guide Upon Discharge from ORR Custody
Upon discharge from ORR custody, I received copies of the following documents:
Notice of Rights and Procedures

ImportaMi 

Immigration Court Locations 


Child Signature

Child Name

Date

Care Provider Staff/Witness Signature

Care Provider Staff/Witness Name and Title

Date

Care Provider Program Name

If the child is unable to sign, mark an “X” in the signature line and provide an explanation below.
Reason child is unable to sign (if applicable)

LRG-5 (ENG) | Version 5
Revised MM/DD/20YY

Page 3 of 3