Form R-3 ORR Release Notification - UC Path Version

OMB 0970-0552 [valid through MM/DD/YYYY]

Administration for Children & Families
Office of Refugee Resettlement

ORR Release Notification

ORR Notification to ICE Chief Counsel Release of Unaccompanied Alien Child to Sponsor
and Request to Change Address
ORR has determined that the below Juvenile Respondent should be released to a sponsor.
The Director of the Office of Refugee Resettlement, Department of Health and Human Services requests that the Chief
Counsel, Immigration and Customs Enforcement, Department of Homeland Security notify the Executive Office of
Immigration Review of the change of address.
Request Details
Date of Request:

[MM/DD/YYYY]

Title:

[Title]

Name of Requestor:

[Name]

Telephone Number:

[(123) 456-7890]
Juvenile Respondent's Biographical Information

Name:

[Name]

Country of Origin:

[Country]

Alias:
A#:

DOB:

[Alias]
[###]

[MM/DD/YYYY]
Release Date and Next Court Appearance

Scheduled Release Date:
Next Scheduled Court Appearance:
Name:
Title:

[MM/DD/YYYY]
[MM/DD/YYYY]
Custodian Information
Telephone Number:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to notify
ICE Chief Counsel of the release of a UAC and request a change of address. Public reporting burden for this collection of information is estimated to average 0.08
hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is
a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you
have any comments on this collection of information, please contact [email protected].

UAC-R-3 [Rev. MM/DD/YYYY]

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ORR Release Notification

Office of Refugee Resettlement

Juvenile Respondent's Prior Address
Program Name (if applicable):

[Program Name]

Alternate Telephone:

[123-456-7890]

Telephone Number:

[123-456-7890]

Prior Street Address
Address:

[Address]

City:

[Value]

State:

[Value]

Zip:

[Value]
Prior Mailing Address (if different)

Address:

[Address]

City:

[Value]

State:

[Value]

Zip:

[12345]

Juvenile Respondent's New Address
Program Name (if applicable):

[Program Name Value]

Alternate Telephone:

[123-456-7890]

Telephone Number:

[123-456-7890]

New Street Address
Address:

[Address]

City:

[Value]

State:

[Value]

Zip:

[12345]

UAC-R-3 [Rev. MM/DD/YYYY]

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ORR Release Notification

Office of Refugee Resettlement

New Mailing Address (if different)
Address:

[Address]

City:

[Value]

State:

[Value]

Zip:

[12345]

ORR certifies that on [ / / ] the Respondent and Sponsor were notified that they must inform Immigration Court
directly of any further change of Address. For releases, notification should be made at least 48 hours in advance. If
notification is not made at least 48 hours in advance of release, please explain reason(s) below.

UAC-R-3 [Rev. MM/DD/YYYY]

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