Form 1 Verification of Release

OMB Control No: 0970-XXXX
Expiration date: XX/XX/XXXX

U.S. Department of Health and Human Services
OFFICE OF REFUGEE RESETTLEMENT
Division of Children's Services
VERIFICATION OF RELEASE

Name of Minor:

Aliases (if any):

Minor's Date of Birth:

Minor's A#:

The Office of Refugee Resettlement (ORR) has released the above named minor from
Federal custody pursuant to section 462 of the Homeland Security Act of 2002 and section
235 of the William Wilberforce Trafficking Victims Protection Reauthorization Act of 2008
to the care of:
Name of Sponsor:
Aliases (if any):
Address:

Tel#:

City:

State:

Zip Code:

Relationship to Child:

Acknowledgement of the Sponsor Care Agreement
The above named sponsor has agreed to the provisions set forth in the Sponsor Care Agreement, pertaining to the minor's
care, safety, and well-being, and the sponsor’s responsibility for ensuring the minor's presence at all future proceedings
before the Department of Homeland Security and the Department of Justice/Executive Office for Immigration Review
(EOIR).

For Internal Use Only
Name ORR care provider
Facility
Date

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of
information is estimated to average .10/hour per response, including the time for reviewing instructions,
gathering and maintaining the data needed, and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number.