Yes
Today M-D-Y
For instructions on how to fill out this form, please open the PDF below.
What is your name (first and last name)?
* must provide value
Name of person completing this form.
What is your email?
* must provide value
What is your phone number?
* must provide value
Which of the following best describes you?
* must provide value
I work at a Resettlement Agency
I am a Private Sponsor
I work in Local Public Health
I work for a Community-Based / Non - Profit Organization
I am a parolee / refugee / asylee
Other
What resettlement agency?
* must provide value
Arrive Ministries Minnesota Council of Churches International Institute of Minnesota Lutheran Social Services Lutheran Social Services - St. Cloud Catholic Charities of Southern Minnesota UCAP
What type of organization are you?
* must provide value
What is the immigration status of the newcomer(s)?
* must provide value
Primary Refugee Parolee Asylee (U.S.-granted) Asylee (derivative) SIV Victim of Trafficking Secondary Refugee Secondary Parolee Secondary SIV Secondary Asylee (U.S.-granted) Secondary Asylee (derivative) Secondary Victim of Trafficking
What Private Sponsor Organization (PSO) is the private sponsor working with?
* must provide value
Alight
HIAS
Other
What other Private Sponsor Organization (PSO) is the private sponsor working with?
Does the family have a case manager that isn't ______
* must provide value
Yes
No
Case manager's name (first and last):
If none, leave blank
Is this a free case? (free case means no family ties)
* must provide value
Yes
No
Family tie's name (first and last):
* must provide value
______ 's phone number:
* must provide value
If unknown, leave blank
Nationality of principal applicant/head of household:
* must provide value
AFGHANISTAN ALBANIA ALGERIA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA ASHMORE AND CARTIER ISLANDS AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS THE BAHRAIN BAKER ISLAND BANGLADESH BARBADOS BASSAS DA INDIA BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERCEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORIES BRITISH VIRGIN ISLANDS BRUNEI BULGARIA BURKINA FASO BURMA BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND CLIPPERTON ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO DEMOCRATIC REPUBLIC COOK ISLANDS CORAL SEA ISLANDS COSTA RICA CROATIA CUBA CYPRUS CZECHOSLOVAKIA CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA EUROPA ISLAND FALKLAND ISLANDS (ISLAS MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN & ANTARCTIC LANDS GABON GAMBIA THE GAZA STRIP GEORGIA GERMANY GHANA GIBRALTAR GLORIOSO ISLANDS GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND & MCDONALD ISLANDS HONDURAS HONG KONG HOWLAND ISLAND HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRAQ-S ARABIA NEUTRAL ZONE IRELAND ISLE OF MAN ISRAEL ITALY IVORY COAST JAMAICA JAN MAYEN JAPAN JARVIS ISLAND JERSEY JOHNSTON ATOLL JORDAN JUAN DE NOVA ISLAND KAZAKHSTAN KENYA KINGMAN REEF KIRIBATI KOREA NORTH (DEMOCRATIC PEOPLES REP) KOREA SOUTH (REPUBLIC OF) KOSOVO KURDS KUWAIT KYRGYZSTAN LAOS/HMONG LAOS/OTHER LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA FEDERATED STATES OF MIDWAY ISLAND MOLDOVA MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE NAMIBIA NAURU NAVASSA ISLAND NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLAND NORWAY NOT SPECIFIED OMAN OTHER PAKISTAN PALMYRA ATOLL PANAMA PAPUA NEW GUINEA PARACEL ISLANDS PARAGUAY PERU PHILIPPINES PITCAIRN ISLANDS POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIA RWANDA SAINT GEORGIS AND THE SOUTH SANDWICH ISLANDS SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH SUDAN REPUBLIC OF SPAIN SPRATLY ISLANDS SRI LANKA SUDAN SURINAME SVALBARD SWAZILAND SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKISTAN TANZANIA UNITED REPUBLIC OF THAILAND TIBET TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TROMELIN ISLAND TRUST TERRITORIES OF PACIFIC TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNKNOWN URUGUAY U.S. MINOR OUTLYING ISLANDS US MISC PACIFIC ISLANDS UZBEKISTAN VANUATU (NEW HEBRIDES) VATICAN CITY VENEZUELA VIETNAM VIRGIN ISLANDS WAKE ISLAND WALLIS AND FUTUNA WEST BANK WESTERN SAHARA WESTERN SAMOA YEMEN YUGOSLAVIA ZAMBIA ZIMBABWE
Format: HB-11111111
Date of arrival to the United States:
Today M-D-Y
Date of arrival to Minnesota:
Today M-D-Y
ALERT: Ukrainian Humanitarian Parolees who arrive on or after 10/01/2023 are no longer eligible for federal Office of Refugee Resettlement (ORR) benefits (including the Refugee Health Assessment) unless they meet specific family reunification criteria (found in the attachment below).
Regardless of eligibility for ORR benefits, the Minnesota Department of Health will continue helping Ukrainian Humanitarian Parolees connect to their required tuberculosis (TB) tests and immunizations. Completing this form will help ensure that the new arrivals receive appropriate services. If you have questions about eligibility, please email refugeehealth@state.mn.us .
Please find more detailed eligibility information in the attachment below:
Does this individual/family meet any of the criteria below:
1. They are the spouse or child (under 21 years old) of someone who entered the US with Ukrainian Humanitarian Parole status before October 1, 2023
* must provide value
Yes
No
Not sure
What is the name of the spouse or child who arrived through Uniting for Ukraine prior to 10-01-2023?
* must provide value
What is ______ 's date of birth?
* must provide value
Today M-D-Y
What is ______ 's Alien number (A#) ?
* must provide value
Primary State of Resettlement:
* must provide value
AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Outside the US
Date of VOT certification / asylum grant:
Today M-D-Y
How many total family members?
* must provide value
Number of people on assurance form
New arrival phone number
* must provide value
If unknown, enter "999-999-9999"
Street address
* must provide value
If unknown, enter "Pending"
If unknown, enter "Pending"
Zip code
* must provide value
If unknown, enter "Pending"
County
* must provide value
Aitkin Anoka Becker Beltrami Benton Big Stone Blue Earth Brown Carlton Carver Cass Chippewa Chisago Clay Clearwater Cook Cottonwood Crow Wing Dakota Dodge Douglas Faribault Fillmore Freeborn Goodhue Grant Hennepin Houston Hubbard Isanti Itasca Jackson Kanabec Kandiyohi Kittson Koochiching Lac Qui Parle Lake Lake of the Woods Le Sueur Lincoln Lyon Mahnomen Marshall Martin McLeod Meeker Mille Lacs Morrison Mower Murray Nicollet Nobles Norman Olmsted Otter Tail Pennington Pine Pipestone Polk Pope Ramsey Red Lake Redwood Renville Rice Rock Roseau St. Louis Scott Sherburne Sibley Stearns Steele Stevens Swift Todd Traverse Wabasha Wadena Waseca Washington Watonwan Wilkin Winona Wright Yellow Medicine Unknown Out of State
Select "Unknown" if county is unknown
Is this their permanent house?
Yes
No
Benton County Contact Information
Cottonwood/Jackson County Contact Information kim.roland@dvhhs.org
Douglas/Grant/Pope/Stevens/Traverse County Contact Information kelseyp@horizonph.org
Lincoln/Lyon/Murray/Pipestone/Redwood/Rock County Contact Information
Renae VanGelderen
OFFICE: 507-532-1265 #
EMAIL: renae.vangelderen@swmhhs.com
Please copy and paste the email of your county contact shown above in the text box below so we can notify them of this new arrival.
* must provide value
Does this family need an interpreter?
* must provide value
Yes
No
What language?
* must provide value
Does this family need transportation?
* must provide value
Yes
No
Please attach the family assurance form
Please attach any relevant biodata, SMC forms, or other medical documentation:
Please attach I94(s) or other immigration documentation for each family member:
I94 isn't required for refugees, but please upload if you have it.
Please attach I94(s) or other immigration documentation for each family member:
I94 isn't required for refugees, but please upload if you have it.
Please attach I94(s) or other immigration documentation for each family member:
I94 isn't required for refugees, but please upload if you have it.
Please attach I94(s) or other immigration documentation for each family member:
I94 isn't required for refugees, but please upload if you have it.
Please attach I94(s) or other immigration documentation for each family member:
I94 isn't required for refugees, but please upload if you have it.
Please attach I94(s) or other immigration documentation for each family member:
I94 isn't required for refugees, but please upload if you have it.
Please attach I94(s) or other immigration documentation for each family member:
I94 isn't required for refugees, but please upload if you have it.
Please attach I94(s) or other immigration documentation for each family member:
I94 isn't required for refugees, but please upload if you have it.
Please attach I94(s) or other immigration documentation for each family member:
I94 isn't required for refugees, but please upload if you have it.
Please attach I94(s) or other immigration documentation for each family member:
I94 isn't required for refugees, but please upload if you have it.
For Ukrainian Humanitarian Parolees who arrived on or after October 1, 2023, please attach any relevant documentation that proves you meet ORR benefit eligibility criteria (marriage certificate, adoption papers, birth certificates, etc.):
Yes
No
Ineligible
Emailed to county (______ ):
Yes
No
NA/UHP
Permanent Address Received?
Yes
No
NA
