Form R-4 Release Request

OMB 0970-#### [Valid through MM/DD/2020]

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:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to process recommendations
and decisions for release of a UAC from ORR custody. Public reporting burden for this collection of information is estimated to average 0.75 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.