Form 1 Repatriation Repayment and Privacy Agreement

OMB Control No:	0970-0474
Expiration Date:
Estimated Burden:	10 minutes

U.S. REPATRIAITON PROGRAM
REPATRIATION REPAYMENT AND PRIVACY AGREEMENT

PAPERWORK REDUCTION ACT OF 1995 (b. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is for the repatriate to accept temporary assistance under the U.S. Repatriation Program; to agree to repay HHS for temporary assistance; and to allow HHS to share personal information for benefits purposes. Public reporting burden for this collection of information is estimated to average 0.17 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: REPATRIATE INFORMATION

1. Repatriate Last Name

2. Repatriate First Name

3. Repatriate Middle Name

4. Address (Street, City, State, Zip Code)

5. Social Security Number

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

7. Phone Number

8. Email Address

SECTION II: ACCEPTANCE OF REPATRIATION SERVICES AND REPAYMENT AGREEMENT

9. Repatriation Services and Repayment Agreement I agree to receive temporary assistance under the U.S. Repatriation Program. I understand that I must repay the U.S. Department of Health and Human Services (HHS) for all financial, medical, shelter, transportation, and other temporary assistance I received through the U.S. Repatriation Program, unless the Office of Human Services Emergency Preparedness and Response (OHSEPR) grants me a waiver. I understand that HHS will bill me directly, and I agree to repay HHS this amount in full. Payment in full is due 30 days after billing. If I pay by installment, or am delinquent in repayment, interest at the current rate fixed by the U.S. Department of the Treasury for private consumer loans will accrue on the unpaid portion, in addition to any fees and penalties. Until I repay the full amount, I agree to report all changes in my address to HHS at 330 C Street S.W., Washington D.C. 20201, Attention: U.S. Repatriation Program. All payments must be sent to: HHS - Program Support Center, Accounting Services – Debt Collection Center, 7700 Wisconsin Avenue, Suite 8310-A, Bethesda, Maryland 20857; Email: PSCDebtServicing@psc.hhs.gov; Telephone: 301-492-4664.

10. Privacy Act Statement I authorize the HHS U.S. Repatriation Program (Program) to collect and have access to my personal identifiable information (PII) including my information on this form and the following Program forms: Emergency Repatriation Eligibility Application (RR-01), Loan Waiver and Deferral Application (RR-03), Routine Repatriation Reimbursement Request (RR-04), and Temporary Assistance Extension Request (RR-07), as applicable. I authorize the Program to disclose my PII to other Federal and state agencies, grantees, service providers, contractors, or private organizations, if necessary for HHS to carry out its responsibilities under 42 U.S.C. 1313 and 24 U.S.C. Sections 321 - 329, or to enable another Federal agency to carry out any functions related to my return from a foreign country to the United States, or as otherwise expressly authorized by appropriate HHS staff, in accordance with 45 CFR 211.14 and 45 CFR 212.9. Providing this information is voluntary, however failure to do so will mean HHS is unable to provide assistance.

SECTION III: SIGNATURE OF REPATRIATE / AUTHORIZED REPRESENTATIVE By signing this document, I certify that I understand and agree to all terms and conditions of the Repayment Agreement and understand the Privacy Act Statement and certify that the information I have provided on this form is true, complete, and accurate to the best of my knowledge. I am aware that any false, fictious, or fraudulent information may subject me to criminal, civil or administrative penalties. (U.S. Code, Title 18, section 1001)

11. Signature

12. Date (MM/DD/YYYY)

SECTION IV: AUTHORIZED REPRESENTATIVE INFORMATION (IF APPLICABLE)

13. Representative Last Name

14. Representative First Name

15. Representative Middle Name

16. Relationship to Repatriate

17. Phone Number

18. Email Address

SECTION V: REPATRIATE DEMOGRAPHIC INFORMATION (VOLUNTARY). Please mark the applicable boxes with “X” that apply for each question. All responses are voluntary.

19. Race ¨ American Indian / Alaskan Native (please specify) _________________________ ¨ Black / African American ¨ Asian ¨ Native Hawaiian or other Pacific Islander ¨ White ¨ Other (please specify) ______________

20. Ethnicity ¨ Hispanic or Latino - a person of Cuban, Mexican, Puerto Rican, Dominican, South or Central American or other Spanish culture or origin, regardless of race ¨ Non-Hispanic or Latino

21. Marital Status ¨ Never Married ¨ Married ¨ Separated ¨ Divorced ¨ Widowed

22. Gender ¨ Male ¨ Female ¨ Nonbinary ¨ Transgender ¨ Other (please specify) _____________ ¨ Prefer not to answer

23. Primary Language ¨ English ¨ Spanish ¨ Mandarin ¨ French ¨ Arabic ¨ Other (please specify) _____________

24. Are you a veteran? ¨ Yes ¨ No

25. Do you have a disability? ¨ Mental ¨ Physical ¨ Emotional ¨ No If yes, please specify: _________________

26. Highest Level of Education ¨ Primary school (K-8th grade) ¨ Some high school ¨ High school graduate / GED ¨ Some college ¨ College degree ¨ Advanced college degree (e.g., Master’s) ¨ Doctorate or Professional Degree (e.g., PhD, JD, MD)

27. Annual Household Income ¨ $0 - $10,000 ¨ $10,001 - $25,000 ¨ $25,001 - $50,000 ¨ $50,001 - $75,000 ¨ $75,001 and above

28. How did you hear about the U.S. Repatriation Program? ¨ Flyer at Airport ¨ Friend or Family ¨ Overseas Evacuation Site ¨ Government Employee ¨ Other: _________________

GENERAL INFORMATION

Purpose: This form is for the repatriate to accept temporary assistance under the U.S. Repatriation Program; to agree to repay HHS for temporary assistance; and to allow HHS to share personal information for benefits purposes.

Who Should Complete 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.

When to Submit: As soon as an eligible individual decides to apply for temporary assistance, but no later than 90 days from the repatriate’s date of arrival in the United States from a foreign country.

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

Disclaimer: Title 18 of the United States Code 1001 provides 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: REPATRIATE INFORMATION

Item 1. Repatriate Last Name. Enter the repatriate’s last name.

Item 2. Repatriate First Name. Enter the repatriate’s first name.

Item 3. Repatriate Middle Name. Enter the repatriate’s middle name. If no middle name, write “NMM.”

Item 4. Address (Street, City, State, Zip Code). Enter the repatriate’s U.S. address. Include apartment/unit number if applicable.

Item 5. Social Security Number. Enter the repatriate’s social security number.

Item 6. Date of Birth (MM/DD/YYYY). Enter repatriate’s date of birth. Format as two-digit month and day and four-digit year.

Item 7. Phone Number. Enter the primary phone number address to send communications regarding participation in the U.S. Repatriation Program.

Item 8. Email Address. Enter the primary email address to send communications regarding participation in the U.S. Repatriation Program.

SECTION II: ACCEPTANCE OF REPATRIATION SERVICES AND REPAYMENT AGREEMENT

Item 9. Repatriation Services and Repayment Agreement. Read in full.

Item 10. Privacy Act Statement. Read in full.

SECTION III: SIGNATURE OF REPATRIATE/ AUTHORIZED REPRESENTATIVE.

Item 11. Signature. Sign to indicate understanding and agreement to all terms and conditions of the Repayment Agreement and the Privacy Act Statement and to certify that the information provided on this form is correct.

Item 12. Date (MM/DD/YYYY). Provide date of signature. Format as two-digit month and day and four-digit year.

SECTION IV: AUTHORIZED REPRESENTATIVE INFORMATION (IF APPLICABLE).

Item 13. Representative Last Name. Enter the authorized representative’s last name.

Item 14. Representative First Name. Enter the authorized representative’s first name.

Item 15. Representative Middle Name. Enter the authorized representative’s middle name.

Item 16. Relationship. Indicate the relationship of the authorized representative to the U.S. citizen (example: parent, legal guardian).

Item 17. Phone Number. Enter the primary phone number address to send communications regarding participation in the U.S. Repatriation Program.

Item 18. Email Address. Enter the primary email address to send communications regarding participation in the U.S. Repatriation Program.

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