R-1 Verification of Release

Administration for Children & Families

Office of Refugee Resettlement

Verification of Release

Child’s Information
PHOTO OF CHILD	Name: [auto-populated from R-4 Release Request]	Date of Birth: [auto-populated from R-4 Release Request]
	Aliases (if any): [auto-populated from R-4 Release Request]	A#: [auto-populated from R-4 Release Request]
	Primary Language: [auto-populated from S-8 Initial Intakes Assessment]	Country of Birth: [auto-populated from P-13 Add New UC]
	Eye 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: [auto-populated from R-4 Release Request]	Address: [auto-populated from R-4 Release Request]
	City: [auto-populated from R-4 Release Request]
Relationship to Child: [auto-populated from R-4 Release Request]	State: [auto-populated from R-4 Release Request]
Primary Phone #: [auto-populated from R-4 Release Request]	Zip Code: [auto-populated from R-4 Release Request]

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). In agreeing to these provisions, the sponsor holds authority to consent to medical and mental health care on behalf of the child.

ORR Care Provider Name: [auto-populated from R-4 Release Request]

Discharge Date: [auto-populated from system-generated date of when child is exited from program]

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. The OMB control number for this information collection is 0970-0552. If you have any comments on this collection of information please contact [email protected].

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