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)

About the child (children)
    1) About the child(ren)
List the name, country of origin, and date of birth for each child you (or the potential sponsor) are applying to sponsor.

Child's First Name
Child’s Last name
Child's Date of Birth
month/day/year (e.g., 12/31/1979)
Child’s UAC Portal ID
Child’s Country of Origin




















About you, the Sponsor
    2) Your name
First name

Last name

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

    4) Your contact information	
Mobile phone number

Secondary phone number (optional)

Email address (optional)

    5) Your country of citizenship				County 1

									Country 2

									Country 3


    6) Either your Social Security
Number (SSN) orYour Tax	SSN	ITIN
Identification Number (ITIN) (if applicable)

7) Your UAC Portal ID 


8) Your previously used name(s)
List other names you have used, such as your name before you were married or maternal last names and when you stopped using them. If no other names, leave blank.

Your Previous Name/Also Known As
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

    7) Your place of birth
Please copy from your birth certificate

City	


Country

Your addresses
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. 

    8) Your current address
Do you have a fixed home or physical address?    Yes   No

If yes, enter your address.
Street Address
(+ apartment number, if applicable)

City/Locality                                                                                              State/Providence   Postal code  

Country 


If no, tell us more about your situation. Are you moving from house to house? Do you not have a place to stay?




Address start date

Month         Year      


    9) Your past addresses
Where have you lived? Include all addresses where you lived from age 18 to today. Please include addresses from your home country.

    • Do your best to provide as much accurate information as possible. Do not leave gaps in your past address timeline.
    • 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. 
    • If you did not have a fixed address at any time, enter “No Fixed Address.” You must still provide the country and dates. Explain your situation in the textbox below. 


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






Tell us more about your no home situation. Were you moving from house to house? Did you not have a place to stay?

















Sponsor Application Packet | Version 20	Page 5 of 5
SAP-2 (ENG) Authorization for Release of Information Revised MM/DD/YYYY