Form 1125-xxxx EOIR-59

U.S Department of Justice
Executive Office for Immigration Review

OMB# 1125-XXXX

Certification and Release of Records

Purpose: The primary purpose for providing the requested information on this form is for parties in cases or
respondents who are in or have been in proceedings before the Executive Office for Immigration Review (EOIR)
proceedings to authorize the disclosure of their information, including information retained in case files or a Record
of Proceeding (documents, and if applicable, audio recordings), to an attorney, accredited representative, qualified
organization, or other third party.
Disclosure: To help to ensure that privacy-protected information is not improperly released, a document such as this
form, which verifies your identity, must accompany all requests for access to records containing your information.
You may choose what information you wish to be disclosed, but failure to fully complete the form, including any
additional information requested to process the request, may delay access to information or result in denial of an
information request.
Authorities: The information requested on this form, and the associated evidence, is collected under the Freedom of
Information Act (FOIA), 5 U.S.C. § 552, and the Privacy Act of 1974, 5 U.S.C. § 552a, together with the Department
of Justice and Executive Office for Immigration Review implementing regulations found in volumes 8 and 28 of the
Code of Federal Regulations.
Freedom of Information Act Statement: Requests for information about a person other than the requester require
proper authorization allowing release of the information. If you are seeking non-public information regarding a person
that is not you or a person you represent, the FOIA Service Center recommends having the person who is the subject
of the request complete and sign this form for this purpose. Failure to provide a signed form EOIR-59 may impede
EOIR’s release of information if the disclosure would constitute a clearly unwarranted invasion of personal privacy.
Additionally, please note that prior to releasing any information, EOIR assesses the applicability of all FOIA
exemptions. For additional information on submitting a FOIA or Privacy Act Request to EOIR, see
https://www.justice.gov/eoir/foia-submit%20a%20request and https://www.justice.gov/eoir/foia-facts.
Paperwork Reduction Act: Under the Paperwork Reduction Act, a person is not required to respond to a collection of
information unless it displays a valid OMB control number. We try to create forms and instructions that are accurate,
can be easily understood, and which impose the least possible burden on you to provide us with information. The
estimated average time to complete this form is six minutes. If you have comments regarding the accuracy of this
estimate, or suggestions for making this form simpler, you can write to the Executive Office for Immigration Review,
Office of the General Counsel, 5107 Leesburg Pike, Suite 2600, Falls Church, Virginia 22041.
Privacy Act Statement. In accordance with 28 CFR §16.41(d), personal data sufficient to identify the individuals
submitting requests by mail under the Privacy Act of 1974, 5 U.S.C. § 552a, is required. This data should at a minimum
include full name, mailing address, and place and date of birth. The purpose of this solicitation is to ensure that the
records of individuals who are the subject of U.S. Department of Justice systems of records are not wrongfully
disclosed by the Department. Requests will not be processed if EOIR cannot confirm identity based on the information
provided. False information on this form may subject the filer to criminal penalties under 18 U.S.C. § 1001 and 5
U.S.C. § 552a(i)(3).

Form EOIR-59
(Rev. October 2020)

U.S Department of Justice
Executive Office for Immigration Review

OMB# 1125-XXXX

Certification and Release of Records

Part A. Information Regarding the Alien or Subject of the Records Sought
1.

Alien Registration Number(s) (if any)

2. Current Legal Name (Last, First, Middle)

3. Other Names You Have Been Known By Since Birth:

4. Current Address in the United States
Street Number and Name

Apartment Number or Unit Number (if any)

City

State

Zip Code

Telephone Number
(

5. Previous Address in the United States (if applicable)
Street Number and Name

City
6. Date of Birth (mm/dd/yyyy)

Apartment Number or Unit Number (if any)

State

Zip Code

7. Country of Nationality or Citizenship

9. (Check One) � Release all of my records

)

Telephone Number
(
)

8. Place of Birth

� Only release the following records: (specify exact records you wish to be released)

Part B. Recipient’s Information
1. Recipient’s Full Name (Last, Middle, First)

2. Recipient’s Organization (if applicable)

3. Recipient’s Mailing Address
In Care of Name (if any)_______________________________________________________________________________________
Street Number and Name

City

Apartment Number

State

Zip Code

Telephone Number
(

)

4. Recipient’s Email Address
5. Recipient’s relationship to subject

6. Recipient’s EOIR-ID Number (if any)

By my signature below, unless otherwise specified above, I consent to EOIR releasing any and all information relating to me to the above-named
Recipient. This consent will allow the Recipient to receive and/or examine potentially sensitive information and documents. If filing this request on
my own behalf, I also consent to pay all costs incurred for search, duplication, and review of documents up to $25.
I further declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the
person named in Part A above, and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a
fine of not more than $10,000 or by imprisonment of not more than five years or both.

Subject of Record’s Signature

Date
Form EOIR-59
(Rev. October 2020)