Form ORR-420/420s Sponsor's Agreement

US Department of Health and Human Services Sponsor’s Agreement to Conditions of Release

OFFICE OF REFUGEE RESETTLEMENT

Division of Unaccompanied Children’s Services

Name of Minor:     	Minor A #:      
Aliases (if any):      	FINS #:      
Name of Sponsor:      	Date:      

Pursuant to Section 462 of the Homeland Security Act, the Office of Refugee Resettlement (ORR) will place the above-named minor into your care and custody, provided that you, as the minor’s custodian, agree to:

• Provide for the physical, mental, and financial well-being of the minor.

• Ensure the minor’s presence at all future proceedings before the Department of Homeland Security (DHS)/Immigration and Customs Enforcement (ICE) and the Executive Office for Immigration Review (EOIR).

• Ensure the minor reports for removal from the United States if so ordered.

• Notify DHS/ICE and EOIR within (5) five days of any change of residence.

• Notify DHS/ICE at least (5) five days prior to your own departure from the United States and indicate whether the departure is voluntary, pursuant to a grant of voluntary departure, or an order of removal.

• Notify DHS/ICE if dependency proceedings involving the minor are initiated and also notify the dependency court of any immigration hearings pending against the minor.

• Receive written permission from DHS/ICE if you decide to transfer custody of the minor to another person. Please note that in the case of an emergency (serious illness, destruction of home, etc), you may temporarily transfer physical custody of the minor to another person prior to securing permission from ICE, but you must notify ICE as soon as it becomes practical and no later than (72) seventy-two hours.

• Notify DHS/ICE as it becomes practical and no later than 72 hours of your learning that the minor has disappeared, has been threatened, or has been contacted in any way by an individual or individuals believed to represent an alien smuggling syndicate or organized crime.

I Understand that release of the above-named minor from the Office of Refugee Resettlement to my custody does not grant the minor any legal immigration status and that the minor must present himself/herself for immigration court proceedings.

Check the circle that applies:

• I received a copy of the above-named minor’s Notice to Appear, DHS Form I-862 (NTA).

• I was not provided a copy of the above-named minor’s Notice to Appear, DHS Form I-862 (NTA).

Sponsor’s Agreement to Conditions of Release

I hereby acknowledge that I have read/had explained to me in my own language, and agree to these conditions of release of the above named minor into my custody. I further understand that DHS/ICE may refer the minor to ORR, and ORR may resume custody if I do not comply with the conditions of the release agreed to in this form.

_________________________________________________________________________________	_________________________________
Signature of Sponsor	Date

Notary Seal:

Sponsor’s Agreement to Conditions of Release, Rev. 3/21/05

ORR R-420

[OMB 0970-0278, valid through 07/31/2011]