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OMB #: 0970-0624 |
Voluntary Agencies Matching Grant Program Data Submission |
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Expiration Date: 02/28/2027 |
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Individual Information Form |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
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24 |
25 |
26 |
27 |
28 |
29 |
30 |
31 |
32 |
33 |
34 |
35 |
Alien Number |
Corrected Alien Number |
First Name |
Middle Name |
Last Name |
DOB |
Immigration Status |
Sex |
Nationality |
Street Address |
Zip Code |
City |
State |
County |
Email |
Phone Number |
Eligibility Date |
Entry Date |
EAD Application Submitted |
EAD Application Submitted Date |
EAD Received |
EAD Received Date |
Social Security Card Application Submitted |
Social Security Card Application Submitted Date |
Social Security Card Received |
Social Security Card Received Date |
SNAP Application Submitted |
SNAP Application Submitted Date |
SNAP Approval |
SNAP Approval Date |
Temporary Housing |
Temporary Housing Type |
Temporary Housing Date |
Long-term Housing |
Long-term Housing Date |
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PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data to better understand client demographics, services utilized, and the outcomes achieved by the population served. The data will be used to inform evidence-based policy making. Public reporting burden for this collection of information is estimated to average 252 hours per grantee in the initial year and 192 hours per year in subsequent years. This includes the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information [Immigration and Nationality Act, section 412(a)(3)]. 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 0970-0264 and the expiration date is 02/28/2027.If you have any comments on this collection of information, please contact MatchingGrant@acf.hhs.gov. |
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In immediate response to priorities of the current administration, this form has been updated with the following changes prior to approval by the Office of Management and Budget (OMB), as required by the Paperwork Reduction Act (PRA) of 1995 (44. USC. 3501 et seq.). The PRA requires that agencies obtain OMB approval before requesting information from the public, and OMB review and approval for most changes to an approved information. ACF is working to process these changes through OMB to come into compliance with the PRA but has implemented changes to the OMB-approved form to ensure compliance with the following Executive Orders: Executive Order(s) 14168 and/or 14151, 14173, 14224. Other than these changes, this form is approved under OMB #: 0970-0624. |
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OMB #: 0970-0624 |
Voluntary Agencies Matching Grant Program Data Submission |
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Expiration Date: 02/28/2027 |
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Matching Grant Enrollment Form |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
Alien Number |
First Name |
Middle Name |
Last Name |
DOB |
MG Case ID |
Principal Applicant (PA) Alien Number |
Relationship to PA |
Affiliate Code |
MG Enrollment Date |
Employable |
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PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data to better understand client demographics, services utilized, and the outcomes achieved by the population served. The data will be used to inform evidence-based policy making. Public reporting burden for this collection of information is estimated to average 252 hours per grantee in the initial year and 192 hours per year in subsequent years. This includes the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information [Immigration and Nationality Act, section 412(a)(3)]. 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 0970-0624 and the expiration date is 02/28/2027. If you have any comments on this collection of information, please contact DRSPrograms@acf.hhs.gov. |
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In immediate response to priorities of the current administration, this form has been updated with the following changes prior to approval by the Office of Management and Budget (OMB), as required by the Paperwork Reduction Act (PRA) of 1995 (44. USC. 3501 et seq.). The PRA requires that agencies obtain OMB approval before requesting information from the public, and OMB review and approval for most changes to an approved information. ACF is working to process these changes through OMB to come into compliance with the PRA but has implemented changes to the OMB-approved form to ensure compliance with the following Executive Orders: Executive Order(s) 14168 and/or 14151, 14173, 14224. Other than these changes, this form is approved under OMB #: 0970-0624. |
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OMB #: 0970-0264 |
Voluntary Agencies Matching Grant Program Data Submission |
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Expiration Date: 02/28/2027 |
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Matching Grant Status Form |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
13 |
14 |
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16 |
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27 |
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29 |
30 |
31 |
32 |
Alien Number |
Affiliate Code |
MG Case ID |
Case Status |
Case Status Date |
180 Day Status |
180 Day Status Date |
180 Day Status Comments |
240 Day Status |
240 Day Status Date |
240 Day Status Comments |
Current Employment Status |
Occupation Categories |
Has Benefits |
Hourly Wage |
Hours Per Week |
Job Start Date |
Job End Date |
Employment Status - Job 2 |
Occupation Categories |
Has Benefits |
Hourly Wage |
Hours Per Week |
Job Start Date |
Job End Date |
Employment Status - Job 3 |
Occupation Categories |
Has Benefits |
Hourly Wage |
Hours Per Week |
Job Start Date |
Job End Date |
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PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data to better understand client demographics, services utilized, and the outcomes achieved by the population served. The data will be used to inform evidence-based policy making. Public reporting burden for this collection of information is estimated to average 252 hours per grantee in the initial year and 192 hours per year in subsequent years. This includes the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information [Immigration and Nationality Act, section 412(a)(3)]. 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 0970-0264 and the expiration date is 02/28/2027. If you have any comments on this collection of information, please contact DRSPrograms@acf.hhs.gov. |
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