Form )RR R-535 )RR R-535 Verification of Release

Office of Refugee Resettlement

US Department of Health and Human Services Verification of Release Form

OFFICE OF REFUGEE RESETTLEMENT

Division of Unaccompanied Children’s Services

Name of Minor:     		Aliases (if any):      
Minor’s Date of Birth:     	Minor’s A #:     		FINS#:      

Photo of Minor

Pursuant to Section 462 of the Homeland Security Act, the Office of Refugee Resettlement (ORR) has released from its custody the above-named minor into the care and custody of:

Name of Sponsor:     			A#:      
Aliases (if any):      			SSN:      
Address:      		Tel #:      
City:      	State:   	Zip Code:      
Relationship to Child:     

Acknowledgement of Conditions of Release

I hereby acknowledge that I have read, or had explained to me in the ____________ language, and I understand the conditions of my release as specified in the Sponsor’s Agreement to Conditions of Release, which include among others the following conditions:

• I agree to appear at all future proceedings before the Department of Homeland Security (DHS)/Immigration and Customs Enforcement (ICE) and the Executive Office for Immigration Review (EOIR).

• I agree to report to the DHS/ICE office if so ordered.

• I agree to notify DHS/ICE if I decide to depart from the United States. I will do this at least 5 days before I actually depart the United States.

• I agree to notify DHS/ICE and EOIR within 5 days of a change of address.

_________________________________________________________	__________________________________________________________
Signature of Alien Minor	Date

_________________________________________________________________________________	_______________     __________
Signature of ORR Official	Release Approved On

For Internal Use Only
ORR/DUCS Facility Name:	     

Verification of Release, Rev. 3/21/05

ORR R-535

[OMB 0970-0278, valid through 06/30/2008]