Form 1 FRP-2

A uthorization for Release of Information

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 (ORR) conducting my background investigation or sponsorship assessment to obtain and receive 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, or my background as a member of the household or care giver for a child, as applicable. 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 my biometric and biographical information, including my fingerprints, is shared with Federal, state, or local law enforcement agencies and may be used consistent with their authorities, including with the U.S. Department of Homeland Security (DHS) to determine my immigration status and criminal history, and with the Department of Justice (DOJ) to investigate my criminal history through the National Criminal Information Center.

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 ORR and may be reviewed by its employees, grantees, contractors, and delegates. I also understand that the ORR 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 ORR or the agency’s official delegate from obtaining the requested information.

I declare and affirm under penalty of perjury that the information contained in this authorization is true and accurate to the best of my knowledge.

YOUR SIGNATURE _________________________________________ DATE _______________

YOUR FULL NAME (PRINT CLEARLY)

___________________________________________________

STAFF USE ONLY
UAC NAME(S)
UAC A#(S)
CARE PROVIDER
DIGITAL SITE LOCATION (IF ANY)

Information required for background check

1) About the minor(s)

List the names and dates of birth of all children you are applying to sponsor

Minor’s Name	Minor’s Date of Birth

2) Your full name (include first name, middle name, and last name)

3) Other names you have used

List other names you have used, such as your name before you were married or maternal last names and when you stopped using them.

Previous name	When you stopped using this name (month/year, e.g., 12/2010)

4) Your date of birth

e.g., 12/31/1979

City

State

County

5) Your place of birth

Where were you born?

Country

6) Addresses: Where have you lived in the last five (5) years?

Street address (+ apartment number, if applicable)	City (Country)	State	Zip code	From date (month/year)	To date (month/year)
(EXAMPLE) 2539 Lowndes Hill Park Road	San Antonio	TX	78201	12/2014	11/2015
Current Address					Current

Immigration Information (if applicable)

If you are not a US citizen, please provide the following information

7a) Alien registration number A#

7b) Country of Citizenship

United States Citizenship information

If you are a U.S. citizen but were not born in the U.S., provide information about at least one of the following proofs of citizenship.

8a) Naturalization Certificate

Court	City	State	Certificate Number	Month/Day/ Year Issued

8b) Citizenship Certificate Where was the certificate issued?

City	State	Certificate Number	Month/Day/Year Issued

8c) State Department Form 240 – Report of Birth Abroad of a Citizen of the United States

Date form was prepared (Month/Day/Year)	Explanation (if needed)

8d) U.S. Passport This may be either a current or previous U.S. Passport

Passport Number	Month/Day/Year Issued

9e) DUAL CITIZENSHIP (if applicable)

Name the country where you are a citizen in addition to the U.S.

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ORR UAC/FRP-2 [Rev. 05/14/2018]

OMB 0970-0278 [valid through 10/31/2018]

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 0.25 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. Please see the accompanying privacy notice / Privacy Act statement for a discussion of (1) the authority for solicitation of information, and whether disclosure is mandatory or voluntary, (2) the principal purposes for which the information is intended to be used, (3) other routine uses which may be made of the information, and (4) the effects, if any, of not providing all or any part of the requested information.