USCIS ROI Release of Information

USCIS ROI Release of Information

This Release of Information (the "Release") is made between Requestor Name: (hereinafter "Requestor") and Recipient Name: (hereinafter "Recipient") on Execution Date: .

RECITALS

WHEREAS, Requestor is an individual whose immigration records are maintained by the United States Citizenship and Immigration Services ("USCIS") and has an identifying USCIS Alien Number (A-Number) A-Number: and Date of Birth: .

WHEREAS, Requestor desires to authorize USCIS and its authorized personnel to disclose specified records and information pertaining to Requestor's immigration files and case history to Recipient for the limited purposes set forth below.

WHEREAS, Recipient is an entity or individual who will receive and act upon the disclosed information as described in this Release, located at Recipient Address: .

NOW, THEREFORE

In consideration of the mutual promises and covenants contained herein, and other good and valuable consideration, the sufficiency of which is hereby acknowledged, the parties agree as follows:

1. AUTHORIZATION

Requestor authorizes USCIS, its officers, employees and agents to disclose to Recipient the records and information described in Section 2. This authorization permits disclosure to Recipient and any of Recipient's authorized agents or representatives identified in writing to USCIS by Recipient.

2. SCOPE OF INFORMATION TO BE RELEASED

The Release includes the following records and information related to Requestor: Case Type: ; USCIS Receipt Number: ; USCIS Office of Record: .

Specific documents and categories to be released (check all that apply):

All records and documents contained in the USCIS file
Application forms and receipt notices
Decisions, notices of intent, and final orders
Biometrics and related records
Other: specify below

3. PURPOSE OF DISCLOSURE

The information may be used by Recipient for the following purpose(s): . Recipient shall use the information only for the stated purpose and shall not further disclose records except as permitted by law or by separate written authorization.

4. DURATION

This authorization is effective for records created on or after From: and until To: , unless earlier revoked in accordance with Section 5.

5. REVOCATION

Requestor may revoke this Release at any time by delivering written notice of revocation to USCIS and to Recipient. Revocation shall not affect disclosures already made in reliance on this Release prior to receipt of the revocation. Method of revocation notice: .

6. FEES AND COSTS

Requestor authorizes USCIS to charge reasonable fees for duplication and search if applicable. Requestor: . Payment arrangements, if any: .

7. USE, CONFIDENTIALITY AND LIMITATIONS

Recipient agrees to maintain the confidentiality of records received and to limit access to those employees, agents, or contractors who have a need to know for the permitted purpose. Recipient shall implement reasonable administrative, technical, and physical safeguards to protect the information from unauthorized use or disclosure. Recipient shall not condition provision of services on Requestor's waiver of any legal rights, except as expressly stated in a separate, written agreement.

8. METHOD OF DISCLOSURE

Select requested method(s) for disclosure:

Mail Email Fax In-person pickup

Recipient Phone:    Recipient Email:

9. AUTHORIZED REPRESENTATIVE

If Requestor designates an authorized representative to receive or review records on Requestor's behalf, provide representative details below. Representative Authorized: Representative Name: Representative Phone/Email:

10. CERTIFICATION, ATTESTATION, AND PENALTIES

Requestor certifies under penalty of perjury that the information provided in this Release is true and correct to the best of Requestor's knowledge. Requestor acknowledges that willfully making a false statement or representation in connection with this Release may subject the Requestor to penalties under federal law, including criminal penalties for false statements and perjury where applicable.

Requestor further acknowledges that USCIS may require verification of identity prior to disclosure and may refuse disclosure if the Requestor's identity cannot be satisfactorily verified or if disclosure would be prohibited by statute or regulation.

11. NOTICES

All notices required or permitted under this Release shall be in writing and delivered to the addresses provided in this document. Notice to Requestor at: . Notice to Recipient at: .

12. AMENDMENT, WAIVER, COUNTERPARTS

This Release may be amended only by a written instrument signed by both Requestor and Recipient. Waiver of any breach or default shall not constitute waiver of any subsequent breach. This Release may be executed in counterparts, each of which shall be deemed an original and together shall constitute one instrument.

13. GOVERNING LAW

This Release shall be governed by and construed in accordance with the laws of the United States and applicable federal regulations governing the disclosure of immigration records. To the extent state law applies, the laws of the state where this Release is executed shall supplement federal law only to the extent not inconsistent with federal law.

14. ENTIRE AGREEMENT; SEVERABILITY

This Release constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether written or oral. If any provision of this Release is held invalid or unenforceable, such provision shall be severed and the remaining provisions shall remain in full force and effect.

15. ADDITIONAL INFORMATION

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