Authorization for Release of Information

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Office of Refugee Resettlement

Authorization for Release of Information
Carefully read this authorization and the accompanying Privacy Notice, then sign and date it.
I Authorize any investigator, special agent, employee, contractor, grantee or other duly accredited representative working on behalf of the Office of Refugee Resettlement (ORR) conducting my background investigation or sponsorship assessment to obtain information for the purposes of assessing my ability to provide appropriate care and placement of a child and for providing post release services, as needed, or my background as a member of the household or caregiver for a child, as applicable. I authorize any federal, state, or local criminal justice agency; federal, state, local, or private child welfare agency; federal immigration agency; or any other sources of information, such as schools, courts, treatment providers, probation/parole officers, mental health professionals, or other references, to release information about any criminal history, child abuse and neglect charges or concerns, mental health issues, substance use, domestic violence, or any other psychosocial information gathered about me either verbally or in writing.
I Authorize custodians of records and sources of information pertaining to me to release such information upon request of the investigator, special agent, employee, contractor, grantee, or other duly accredited representative of the Office of Refugee Resettlement.
I Understand that my biometric and biographical information, including my fingerprints and my photograph, is shared with Federal, state or local law enforcement agencies and may be used consistent with their authorities, including with the U.S. Department of Homeland Security (DHS) and with the U.S. Department of Justice (DOJ) to investigate my criminal history through the National Criminal Information Center.

I Understand that the information released by any custodian of my records and any other sources of information about me is for official use by the U.S. Government, its employees, grantees, contractors, and other delegated personnel, for the purposes stated above, and may be disclosed by the U.S. Government only as authorized by law.
I Understand that this information will become the property of the ORR and may be reviewed by its employees, grantees, contractors, and delegates. I also understand that the ORR may share this information with the employees and contractors of other Federal agencies.

I Understand that, if applicable, ORR will offer me a fingerprint appointment within seven (7) business days of receipt of a signed copy of this document and a valid form of identification, unless circumstances beyond ORR’s


control prevent ORR from offering an appointment within that timeframe. I further understand that ORR will make reasonable efforts to process my fingerprints within ten (10) business days of receipt of a set of legible prints, unless circumstances beyond ORR’s control prevent fingerprints from being processed within that timeframe.

I Hereby Relinquish any claim or right under the laws of the United States against the federal government, its employees, grantees, contractors, or delegates, for the legally authorized use of any information gathered during a search of my criminal history, child welfare information, any information contained in my sponsorship application and supporting documentation, and any information gathered from any verbal or written sources regarding this sponsorship application. I hereby relinquish any claim or previous agreement with any federal, state, local, or private agency that would bar the ORR or the agency's official delegate from obtaining the requested information.


I declare and affirm under penalty of perjury that the information contained in this authorization is true and accurate to the best of my knowledge. I understand that knowingly and willfully falsifying, concealing, or covering up a material fact, or making any materially false, fictitious, or fraudulent statement or representation, or making or using any false writing or document knowing it contains any materially false, fictitious, or fraudulent statement or entry, is a violation of 18 U.S.C. § 1001 and may subject me to fines, imprisonment, or both. ORR may report fraudulent information to Federal law enforcement. (Sign, date, and print your name)


YOUR SIGNATURE	DATE

YOUR FULL NAME (PRINT CLEARLY)


STAFF USE ONLY
UAC NAME(S)

UAC A#(S)

CARE PROVIDER

DIGITAL SITE LOCATION (IF ANY)

Background
    1) About the child(ren)
List the names, country of origin, and dates of birth of all children you (or the potential sponsor) are applying to sponsor.

Child's Name
Child’s Country of Origin
Child's Date of Birth
month/day/year (e.g., 12/31/1979)












    2) Your full name
Include first name, middle name, and last name.

    3) Other names you have used
List other names you have used, such as your name before you were married or maternal last names and when you stopped using them.

Previous Name
Are you still using this name?
When you stopped using this name (if applicable) month/year (e.g., 12/2010)

 Yes No


 Yes No


 Yes No

    4) Your date of birth
month/day/year (e.g., 12/31/1979)

    5) Your place of birth
Where were you born?
City	


	Country


    6) Your country of citizenship
    7) Either your Social Security
Number (SSN) or Your Tax	SSN	ITIN
Identification Number (ITIN) (if applicable)
    8) Phone numbers	Primary Phone
e.g., 210-555-1234
Secondary Phone

    9) Your email address

    10) Addresses
Where have you lived? Include all addresses where you lived from age 18 to today.

Do your best to provide as much accurate information as possible. If you do not know your street address, enter “Unable to Recall Address”. You must still provide the City, State, or Country and the dates. Instead, enter the information you know is correct and then explain in the textbox below why you are unable to provide the full address(es).

Street address
(+ apartment number, if
applicable)
City/Locality, State/Province

Postal code

Country
From date
(month/year)
To date
(month/year)
(EXAMPLE)
2539 Lowndes Hill Park Road
San Antonio, TX
78201
USA
12/2014
11/2015





Current






























Your Current Address:  
Did you have a fixed home or physical address during this time?		  Yes No
Tell us more about no home situation. Were you moving from house to house? Did you not have a place to stay?

Please explain if you are unable to provide the full address history requested.

    11) File Uploads

    a.  Sponsor Proof of Identity: All potential sponsors must provide at least one (1) identification document that contains a photograph for all such adults. The document must be from the list of acceptable documents below and must be an unexpired, original version or a legible full color photocopy, digital scan, or digital photo of a government-issued photo ID.
    b. Sponsor photo (selfie). All potential sponsors must provide a current photo of themselves (selfie) to support verification of their identity.

Acceptable Proof of Identity Documents
U.S. Passport or U.S. Passport Card
Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
Employment Authorization Document that contains a photograph (Form I-766)
Foreign passport with Form I-94 or Form I-94A with Arrival-Departure Record, and containing an endorsement to work
Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
Driver’s license or ID card issued by a U.S. state or outlying possession of the United States provided it contains a photograph or information such as a name, date or birth, sex, height, eye color, and address
ID card issued by U.S. federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, sex, height, eye color, and address
U.S. Military card or draft record
U.S. Military dependent’s ID card
U.S. Coast Guard Merchant Mariner Card
Native American tribal document
Driver’s license issued by a Canadian government authority





















Sponsor Application Packet | Version 19	Page 5 of 5
SAP-2 (ENG) Authorization for Release of Information Revised MM/DD/YYYY