ORR R-317 Authorization for Release Information/English Page 2

OFFICE OF REFUGEE RESETTLEMENT

INFORMATION REQUIRED FOR BACKGROUND CHECK

CHILD’S NAME:

CHILD’S A# (to be completed by facility):

SPONSOR’S INFORMATION:

DATE OF BIRTH

Last Name

First Name

Middle Name (Suffix)

Month

Day

Year

SEX: MALE ( ) FEMALE ( )

Race

Eye Color

SOCIAL SECURITY NUMBER (optional)*

Height

Weight

Hair Color

PLACE OF BIRTH: (Use two letter code for State)

City

County

State

Country

OTHER NAMES USED AND DATES WHEN USED:

Name

From Month Year

To Month Year

Name

From Month Year

To Month Year

RESIDENCES IN LAST 5 YEARS:

FROM: Month/Year TO: Month/Year

Street Address Apt. #

City (Country)

S tate

Zip Code

FROM: Month/Year TO: Month/Year

Street Address Apt. #

City (Country)

S tate

Zip Code

FROM: Month/Year TO: Month/Year

Street Address Apt. #

City (Country)

S tate

Zip Code

FROM: Month/Year TO: Month/Year

Street Address Apt. #

City (Country)

S tate

Zip Code

UNITED STATES CITIZENSHIP. If sponsor is a U.S. Citizen, but was not born in the U.S., provide information about one or more of the following proofs of citizenship.

Naturalization Certificate

Court

City

State

Certificate Number

Month/Day/Year Issued

Citizenship Certificate (Where was the certificate issued?)

City

State

Certificate Number

Month/Day/Year Issued

State Department Form 240 – Report of Birth Abroad of a Citizen of the United States

Give the date the form was prepared and give an explanation if needed.

Month/Day/Year

Explanation

U.S. Passport

This may be either a current or previous U.S. Passport

Passport Number

Month/Day/Year Issued

DUAL CITIZENSHIP - If subject is (or was) a dual citizen of the United States and another country, provide the name of that country in the space to the right.

Country

c. ALIEN If subject is an alien, provide the following information:

Place Entered the United States

City

State

Date Entered U.S. M onth Day Year

Alien Registration Number

Country of Citizenship

* The provision of the Social Security Number is not mandatory. However, if not provided, ORR may be unable to complete the background check necessary for the reunification procedure.

Authorization for Release of Information, Rev. 3/21/05

ORR R-317

[OMB 0970-0278, valid through 06/30/2008]

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