Form 1 Release Request

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average .24/hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
OMB Control No: 0970-XXXX; Expiration date: XX/XX/XXXX

UC Basic Information
First Name:
Last Name:

AKA:
Status:
Date of Birth:
A No.:
Age:
Country of Birth:

Gender:
LOS:
Current Program:
Admitted Date:
Release Request

Requester Information
Requester Name:
Requester Title:
Requester Phone:

Type of Release:

Sponsor Information
Name of Sponsor:
AKA
Date of Birth:

Current Age:

Country of Birth:

Legal Status:

If Other Non‐Immigrant Visa, Specify:
If Other Immigrant Visa, Specify:
A Number:
Sponsor Email:
Sponsor's Relationship to Minor:
Yes No
Is There Proof of the Relationship?
Provide Details on Relationship Including Official Documentation:
Sponsor Household Occupants:
Affidavits of Support:
Case Manager Recommendation
Case Manager Name:
Comments:
Is Attorney Contacted?:
Yes No
Case Manager Recommendation after
Home Study:
Case Coordinator Recommendation
Case Coordinator Name:
Comments:
Recommendation:
Sponsorship Cancellation Recommendation Reason:
ORR Decision
Comments:
Approve Straight Release
ORR Decision:
ORR Decision after Home Study:
Program Release Dates
Release Approved Date:

Release to Sponsor

SSN:

Case Manager Recommendation:
If Applicable, Cancellation Reason:

Recommendation after Home Study:

Home Study Status:

Release Scheduled Date:

Release to Program

Release Approved by:
The Next Scheduled Court Appearance for This Juvenile is:
Date Sponsor was Notified that They Must Inform the Immigration Court Directly of any Further
Change of Address:
Reason for Less Than 24 Hours Notice to ICE, if Applicable: