Form R-3 Notice to ICE Chief Counsel - Release of Unaccompanied A

OMB 0970-#### [Valid through MM/DD/2020]
ORR Release Notification
ORR NOTIFICATION TO ICE CHIEF COUNSEL RELEASE OF UNACCOMPANIED
ALIEN CHILD TO SPONSOR AND REQUEST TO CHANGE ADDRESS

ORR has determined that the below Juvenile Respondent should be released to a sponsor. The Director of the Office of Refugee
Resetlement, Department of Health and Human Services requests that the Chief Counsel, Immigration and Customs
Enforcement, Department of Homeland Security notify the Executive Office of Immigration Review of the change of address.
Date of Request:

Name of Requestor

Title

Telephone Number

Juvenile Respondent's Allien Number, complete name and aliases, date of birth and claimed country of origin:
1. Juvenile respondent's biographical information
Name:

A#:

Aliases (if any):

DOB:

Country of Origin:
Juvenile Respondent's prior Address:

Program Name (if Applicable):
Street Address

Mailing Address (if different)

City

State

Zip

Telephone Number

City

State

Zip

State

Zip

Alternate Telephone #

Juvenile Respondent's new Address:

Program Name (if Applicable):
Street Address

City

Mailing Address (if different)

State

Zip

Telephone Number

City

Alternate Telephone #

Custodian Information:
Name

Title relationship

Telephone Number

The Release is scheduled to take place on :
The next scheduled court appearance for this juvenile is:
ORR certifies that on: the Respondent and Sponsor ware notified that they must inform Immigration Court directly of any further
change of address
For releases, notification should be made at least 48 hours in advance. If notification is not made at least 48 hours in advance of
release, please explain reason(s) below.

cc: Attorney of Record
DHS/ICE/DRO

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this
information collection is to allow ORR to notify ICE Chief Counsel of the release of a UAC and request a change of address. Public
reporting burden for this collection of information is estimated to average 0.05 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. If you have any comments on this collection of information please contact UACPolicy@acf.hhs.gov.