Form FRP-2 Authorization for Release of Informaiton

OFFICE OF REFUGEE RESETTLEMENT

CONFIDENTIAL AND PRIVILEGED

STAFF USE ONLY:

UAC NAME:      

UAC A#:      

CARE PROVIDER:      

DIGITAL SITE LOCATION (IF ANY):      

U.S. Department of Health and Human Services

Carefully read this authorization, then sign and date it in black ink.

I Authorize any investigator, special agent, employee, contractor, grantee or other duly accredited representative working on behalf of the Office of Refugee Resettlement conducting my background investigation and sponsorship assessment to obtain information for the purposes of assessing my ability to provide appropriate care and placement of a child and for providing post release services, as needed. I authorize any federal, state, or local criminal justice agency; federal, state, local, or private child welfare agency; federal immigration agency; or any other sources of information, such as schools, courts, treatment providers, probation/parole officers, mental health professionals, or other references, to release information about any criminal history, child abuse and neglect charges or concerns, past and present immigration status, mental health issues, substance abuse, domestic violence, or any other psychosocial information gathered about me either verbally or in writing.

I Authorize custodians of records and sources of information pertaining to me to release such information upon request of the investigator, special agent, employee, contractor, grantee, or other duly accredited representative of the Office of Refugee Resettlement.

I Understand that the information released by any custodian of my records and any other sources of information about me is for official use by the U.S. Government, its employees, grantees, contractors, and other delegated personnel, for the purposes stated above, and may be disclosed by the U.S. Government only as authorized by law.

I Understand that this information will become the property of the Office of Refugee Resettlement and may be reviewed by its employees, grantees, contractors, and delegates. I also understand that the Office of Refugee Resettlement may share this information with the employees and contractors of other Federal agencies.

I Hereby Relinquish any claim or right under the laws of the United States against the federal government, its employees, grantees, contractors, or delegates, for the legally authorized use of any information gathered during a search of my criminal history, child welfare information, past or present immigration status, any information contained in my sponsorship application and supporting documentation, and any information gathered from any verbal or written sources regarding this sponsorship application. I hereby relinquish any claim or previous agreement with any federal, state, local, or private agency that would bar the Office of Refugee Resettlement or the agency’s official delegate from obtaining the requested information.

Copies of this authorization that show my signature are as valid as the original. This authorization is valid for one (1) year from the date signed.

Signature (Sign in ink)	Full Name (Type or Print Legibly)      			Date Signed      
Other names used (AKA)      	Sponsor’s DOB      			Social Security Number (optional)*      
Current Address      		State   	ZIP Code      	Home Telephone Number (Include Area Code) (   )    -    

^*The provision of the Social Security Number is not mandatory. However, if not provided, ORR may be unable to complete the background check necessary for the reunification procedure.

INFORMATION REQUIRED FOR BACKGROUND CHECK

CHILD’S NAME:

CHILD’S DATE OF BIRTH:

     

     

SPONSOR’S INFORMATION:

DATE OF BIRTH

Last Name      

First Name      

Middle Name (Suffix)      

Month   

Day   

Year     

SEX: MALE FEMALE

Race      

Eye Color      

SOCIAL SECURITY NUMBER (optional)*

Height      

Weight      

Hair Color      

   

  

    

PLACE OF BIRTH: (Use two letter code for State)

City      

County      

State   

Country      

OTHER NAMES USED AND DATES WHEN USED:

Name      

From:       Month Year

To:       Month Year

Name      

From:       Month Year

To:       Month Year

RESIDENCES IN LAST 5 YEARS:

FROM: Month/Year       TO: Month/Year      

Street Address Apt. #     

City (Country)      

State    

Zip Code      

FROM: Month/Year       TO: Month/Year      

Street Address Apt. #     

City (Country)      

State    

Zip Code      

FROM: Month/Year       TO: Month/Year      

Street Address Apt. #     

City (Country)      

State    

Zip Code      

FROM: Month/Year       TO: Month/Year      

Street Address Apt. #     

City (Country)      

State    

Zip Code      

UNITED STATES CITIZENSHIP. If sponsor is a U.S. Citizen, but was not born in the U.S., provide information about one or more of the following proofs of citizenship.

Naturalization Certificate

Court      

City      

State   

Certificate Number      

Month/Day/Year Issued      

Citizenship Certificate (Where was the certificate issued?)

City      

State   

Certificate Number      

Month/Day/Year Issued      

State Department Form 240 – Report of Birth Abroad of a Citizen of the United States

Give the date the form was prepared and give an explanation if needed.

Month/Day/Year      

Explanation      

U.S. Passport

This may be either a current or previous U.S. Passport

Passport Number      

Month/Day/Year Issued      

DUAL CITIZENSHIP – If subject is (or was) a dual citizen of the United States and another country, provide the name of that country in the space to the right.

Country      

ALIEN If subject is an alien, provide the following information:

Place Entered the United States

City      

State   

Date Entered U.S. Month Day Year           

Alien Registration Number      

Country of Citizenship      

* The provision of the Social Security Number is not mandatory. However, if not provided, ORR may be unable to complete the background check necessary for the reunification procedure.