R-1 Verification of Release - UC Path version

OMB 0970-0552 [valid through MM/DD/20YY]

Administration for Children & Families
Office of Refugee Resettlement

Verification of Release
Minor Information

PHOTO OF MINOR

Name of Minor:

Minor’s Date of Birth:

Aliases (if any):

Minor’s A#:

Height:

Weight:

Eye Color:

Hair Color:

Sponsor Information
The Office of Refugee Resettlement (ORR) has released the above named minor from Federal custody pursuant to section
462 of the Homeland Security Act of 2002 and section 235 of the William Wilberforce Trafficking Victims Protection
Reauthorization Act of 2008 to the care of:
Name of Sponsor:

Address:

Aliases (if any):

City:

Relationship to Child:

State:

Telephone #:

Zip Code:

Acknowledgement 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 Department of Homeland Security and the Department of Justice/Executive Office for
Immigration Review (EOIR).
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
UC and their sponsors with official documentation showing that ORR released the UC 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].

R-1 [MM/DD/2022]

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