U.S. Repatriation Emergency and Group Processing Form

Instructions: Please complete ONE FORM per individual or nuclear family. Include extra pages if space is not sufficient to provide the requested information. Please WRITE the applicant’s name on the right hand corner of each additional page. This form should be returned to the above address or electronically as instructed by the authorized federal staff.

1. Who is eligible?

Applicants for temporary assistance must be U.S. citizens or dependents of U.S. citizens who have been returned or brought back to the U.S. due to a Department of State’s ordered or authorized evacuation from overseas because of war, threat of war, or similar crisis, and the person does not have resources immediately available to meet their needs. In addition, U.S. nationals may be eligible under 24 U.S.C. Sections 321 through 329.

2. Who should complete this form?

Physical presence of individuals requesting HHS Repatriation temporary assistance is ordinarily required at the time of application. Limited exceptions may apply. For further information and guidance on these limitations please consult with the designated Administration for Children and Families (ACF) staff. Intake staff at the U.S Emergency Repatriation Center (ERC) can assist with the completion of this form.

Below is a list of who can sign this form:

• Only those who fall within the above question 1
• Adults applying for themselves
• Adults applying on behalf of themselves and dependents
• Adult representative of a minor child (parent, guardian, or legal representative)
• Adult representative of a mentally or physically impaired adult

3. Disclaimer:

Eligibility determinations are made by authorized staff from the ACF in the Department of Health and Human Services (HHS), in accordance to 45 CFR 211 and 212. The statutory authority for this collection is 42 U.S.C. Sections 1313, 24 U.S.C. Sections 321 through 329, and the Health Insurance Portability and Accountability Act of 1996. Information solicited on this repatriation form is for the purpose of determining your eligibility for temporary assistance under the Program. Furnishing the information on this form, including but not limited to the social security number, is voluntary. However, if you fail to provide the requested information, you may be found ineligible for repatriation assistance. Personal information provided on this form may only be disclosed for Program purposes or under the conditions prescribe in 45 CFR 211.14 or 45 C.F.R.212.9.