Form R-1 Verification of Release - UC Path version

OMB 0970-0552

Administration for Children & Families
Office of Refugee Resettlement

Verification of Release
Minor Information

[PHOTO]

Name of Minor:

Minor’s Date of Birth:

Aliases (if any):

Minor’s A#:

Sponsor Information
The Office of Refugee Resettlement (ORR) has approved released of the above named minor from the U.S. Department of
Health and Human Service's custody pursuant to, pursuant to 6 U.S.C. 279 and 8 U.S.C. 1232, to the care of:
Name of Sponsor:

Address:

Relationship to Child:

State:

Aliases (if any):
Telephone #:

City:

Zip Code:

Acknowledgment 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 U.S. Department of Homeland Security and the U.S. Department of Justice.

Name of ORR Care Provider:
Date:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide UAC and their sponsors with official documentation
showing that ORR released the UAC into the sponsor's care and custody. Public reporting burden for this collection of information is estimated to average 0.17 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-1 [Rev. MM/DD/YYYY]

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