U.S. Refugee Admissions Program

SIV RESETTLEMENT AGREEMENT / BIODATA FORM

Page 1 of 5

I have provided up-to-date and accurate contact information (address, email, phone number) for relatives or friends in the United States with whom I would like to resettle in this form. I have provided names of my relatives or friends in the United States in this form, but I do not have any contact information for them. I understand that I will not be placed in the area of my relatives or friends. I do not have any relatives or friends in the United States with whom I would like to resettle with, and accept the location that the USRAP identifies for me to resettle to. I have provided names and contact information (if available) for my relatives or friends in the United States in this form, but do not want to be resettled with or near them, and accept the location that the USRAP identifies for me to resettle to.

The following are important points for applicants regarding placement in the United States:

− I understand the importance of providing accurate and up-to-date contact information (address, email, phone number) of my U.S. tie for the purposes of resettlement. I understand that the USRAP will try to place me near my friends and family in the United States, however it is possible that I will be placed in a different location.

− I understand that I may provide my U.S. tie’s detailed information, or updates to my U.S. tie’s information or my resettlement preferences, within 14 days of receiving this form. After this point, changes to my U.S. tie or resettlement preference will not be accepted.

− My placement in the United States will be affected if the contact information (address, email, phone number) I provided regarding my U.S. tie is not complete or accurate. Incomplete or inaccurate contact information may lead me to being placed in a location other than my preferred locations.

− I understand that the U.S. resettlement program will not accept any requests to redirect my travel or may not be able to transfer my case once I arrive in the United States. If I choose to migrate to a location other than the location selected for me before the U.S. Government support is completed, it is possible that I will not receive some of the U.S. Government-funded services normally provided to newly arriving refugees.

− Resettlement, including being received in the United States, is free of charge. My U.S. tie is not required to pay any money for my arrival in the United States, although in some impacted locations, they may be required to provide temporary or permanent housing for me or otherwise assist the resettlement agency with securing housing for me.

By checking the box and entering my name below, I confirm my understanding of the USRAP’s placement policies as detailed above, and I have provided accurate contact information within this form for any U.S. ties that I wish to be placed near in the U.S. Printed name of PA Date dd mmm yyyy

Please review and acknowledge the below resettlement agreement and fill out this form, in its entirety, with information about your USRAP resettlement case. If your case is approved for admission to the United States, the information provided will help with placement and resettlement. Please select one of the options below:

IV Case Number

CASE INFORMATION

Immigrant Visa Number

Case size

INFORMATION ABOUT YOURSELF (PRINCIPAL APPLICANT)

Full Name Surname, Given Name(s)

Date of Birth dd mmm yyyy

Sex

Marital Status

Phone number

Email address

Ethnicity

Religion

Preferred/Primary/Native Language:

Speaking Ability in Native Language

Writing Ability in Native Language

Reading Ability in Native Language

English Language:

Speaking Ability in English

Writing Ability in English

Reading Ability in English

INFORMATION ABOUT YOUR SPOUSE

Spouse Full Name Surname, Given Name(s)

Date of Birth dd mmm yyyy

Sex

Is your Spouse your first cousin? *

Ethnicity

Religion

Preferred / Native Language:

Speaking Ability in Native Language

Writing Ability in Native Language

Reading Ability in Native Language

English Language:

Speaking Ability in English

Writing Ability in English

Reading Ability in English

* If your spouse is your first cousin, you cannot be resettled to certain areas because first cousin marriages are prohibited or not recognized. Page 2 of 5

U.S. Refugee Admissions Programm

SIV RESETTLEMENT AGREEMENT / BIODATA FORM

U.S. Refugee Admissions Program

SIV RESETTLEMENT AGREEMENT / BIODATA FORM

Page 3 of 5

INFORMATION ABOUT YOUR CHILDREN

List all your children and their date(s) of birth for your Immigration Case below ex: SMITH, John 2009-07-04

SMITH, Jane 2022-11-25

INFORMATION ABOUT YOUR HEALTH

Do you or any members of your family have any of the following classifications of significant health conditions, or are currently pregnant? Developmental,

Neurological, or

Psychological Issues

such as:

− Autism

− Cerebral palsy

− Cleft palate

− Down syndrome

− Epilepsy or seizure

− Paranoia-diagnosed

− Parkinson’s

− Schizophrenia

− Spina Bifida

Mobility or Sensory

Issues such as:

− Blind

− Deaf

− Mute

− Missing major limbs

(amputation or deformity)

− Paralysis

− Wheelchair bound

Significant Health

Conditions or

Diseases such as:

− Burnt Body Parts

(needing skin graft or

impacts movement)

− Cancer

− Heart disease

− Hydrocephaly / hydrocephalus

− Hypertrophic cardiomyopathy

− Idiopathic Thrombocytopenic

Purpura

− Kidney failure (requiring

dialysis)

− Leukemia

− Lupus

− Multiple sclerosis

− Polio

− Organ transplant

required

Family Member Pregnant?

Developmental,

Neurological, or

Psychological Issues?

Mobility or

Sensory

Issues?

Other Significant

Health Conditions

or Diseases?

Yourself (Principal

Applicant)

Spouse

Any of your Children

Do you have any children on your Immigration case? Page 4 of 5

U.S. Tie #1 (Family or friend you would prefer to live near in the US. list your top choice first.) Full Name Surname, Given Name(s)

Relationship to Applicant

Sex

Street Address

City

State

Zip Code

Phone Number

Email Address

If you and your spouse are first cousins, you cannot be resettled to the following states where first cousin marriage is not allowed / not recognized, even if you indicate a U.S. Tie. Arizona (AZ) Union/sex a felony for spouses who are first cousins Delaware (DE) Marriages not legally recognized for spouses who are first cousins Illinois (IL) Marriages not legally recognized for spouses who are first cousins Kentucky (KY) Marriages not legally recognized for spouses who are first cousins Mississippi (MI) Union/sex a felony for spouses who are first cousins Nevada (NV) Union/sex a felony for spouses who are first cousins New Hampshire (NH) Marriages not legally recognized for spouses who are first cousins North Dakota (ND) Union/sex a felony for spouses who are first cousins Texas (TX) Union/sex a felony for spouses who are first cousins Utah (UT) Union/sex a felony for spouses who are first cousins Wisconsin (WI) Union/sex a felony for spouses who are first cousins Full Name Surname, Given Name(s)

Relationship to Applicant

Sex

Street Address

City

State

Zip Code

Phone Number

Email Address

U.S. Tie #2

U.S. Refugee Admissions Programm

SIV RESETTLEMENT AGREEMENT / BIODATA FORM

Do you have a Welcome Corps Private Sponsor**?

** Welcome Corps private sponsors are a group of five or more Americans who have applied to support you upon arrival in the United States. A Welcome Corps sponsor group is different from a U.S. Tie. Private Sponsor Group’s Affiliate ID (ex. NY CSH 01) Page 5 of 5

Family Member Name

Surname, Given Name

Relationship

to you

Date of Birth

dd mmm yyyy

1

3

2

(Optional) Please list other family members with active U.S. immigration cases, with whom you wish to be resettled with. There is no guarantee that requests to resettle with family members on other cases can be honored, and could result in delays in processing. Case Number of

Family Member

U.S. Tie #3

Full Name Surname, Given Name(s)

Relationship to Applicant

Sex

Street Address

City

State

Zip Code

Phone Number

Email Address

U.S. Refugee Admissions Programm

SIV RESETTLEMENT AGREEMENT / BIODATA FORM

Contact this candidate