Form 1125-0017 Certification and Release of Records

U.S Department of Justice OMB# 1125-0017

Executive Office for Immigration Review Certification and Release of Records

Purpose: The primary purpose for providing the requested information on this form is for parties in cases or individuals who are in or have been in proceedings before the Executive Office for Immigration Review (EOIR) 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 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 who 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. If a disclosure would constitute a clearly unwarranted invasion of personal privacy, EOIR may not release the requested information without a signed form EOIR-59. 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-a-request.

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 ten 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 C.F.R. § 16.41, personal data sufficient to identify the individual 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 and guardianship 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).

Part A. Information Regarding the Noncitizen or Subject of the Records Sought
Alien Registration Number(s) (A-numbers) (if any)		2. Current Legal Name (Last, First, Middle)
3. Other Names By Which You Have Been Known Since Birth:
4. Current Address (Note: If you are a noncitizen and your address has changed, please complete the EOIR-33, Change of Address/Contact Information Form, available at https://www.justice.gov/eoir/list-downloadable-eoir-forms.) Street Number and Name Apartment Number or Unit Number (if any)
City and State or Province			Country	Zip Code (if any)			Telephone Number ( )
5. Previous Address (if applicable) Street Number and Name Apartment Number or Unit Number (if any)
City and State or Province			Country		Zip Code (if any)	Telephone Number ( )
6. Date of Birth (mm/dd/yyyy)	7. Country of Nationality or Citizenship				8. Place of Birth
9. (Check One) 󠇄 ☐ Release all of my records 󠇄 ☐ Only release the following records: (specify exact records you wish to be released)

Part B. Recipient’s Information
Recipient’s Full Name (Last, Middle, First)		Recipient’s Organization (if applicable)
3. Recipient’s Mailing Address In Care of Name (if any)_______________________________________________________________________________________ Street Number and Name Apartment Number or Unit Number (if any)
City and State or Province	Country		Zip Code (if any)	Telephone Number ( )
4. Recipient’s Email Address
5. Recipient’s Relationship to Subject of Record
☐Attorney or legal representative. Proceed to 6.	☐Parent or guardian. If signing on behalf of Subject of Record, you must complete Part C.		☐ Other. Please specify:
6. Recipient’s EOIR-ID Number (if any)

Part C. Parent or Guardian Information You must complete this part if you are the parent or guardian of the Subject of Record and you are completing this form on behalf of the Subject of Record.
1. Date of Birth (mm/dd/yyyy)	2. Place of Birth
3. Current Address Street Number and Name Apartment Number or Unit Number (if any)
City and State or Province	Country	Zip Code (if any)
4. Relation to Subject of Record: __________________________________________________ ☐ By checking this box, I understand that 28 C.F.R. § 16.41 requires that I attach proof of my relationship to the subject of the record if I am requesting a copy of a Record of Proceeding or requesting copies of records under the Freedom of Information Act or the Privacy Act.

Part D. Signature of Noncitizen, Subject of Record, or Parent or Guardian of Subject of Record 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.

1. Signature

2. Date

Form EOIR-59

Rev. Aug. 2023