Fillable Printable 60 001
Fillable Printable 60 001
60 001
Use this form to authorize the U.S. Department of Homeland Security (“DHS”) to disclose information and/or records about you to a
third party. Taking this action is entirely voluntary; you are under no obligation to consent to the release of your information to any third
party. Authority: Privacy Act of 1974 (5 U.S.C. § 552a); DHS Privacy Act Regulations (6 C.F.R. § 5.21(d)).
STEP 1
Provide information about yourself and identify the third party that you intend to receive
your information and/or records (the “Recipient”).
Your Full Name: Your Alien Registration Number (if applicable):
Your Current Address:
Date of Birth:
Country of Birth:
Recipient's Name: Recipient's Phone Number:
Recipient's Mailing Address (required if requesting disclosure by mail):
Recipient's Organization,
if the waiver will apply to it (e.g. news media, congressional office, law firm):
Specify what information and/or records DHS is authorized to share with the Recipient.
STEP 2
AND/OR
ICE Form 60-001 (2/11)
OR
For Aliens Only: If you have applied for or received any of the immigration benefits below, you are legally entitled to confidentiality.
(See reverse for more information.) If you want DHS to share information about these benefits with the Recipient, you must waive
your confidentiality rights by checking the appropriate boxes below. Waiver of these rights is not required; however, if you do not
waive these rights DHS may be unable to disclose to the Recipient some or all of the information you identified above.
I waive my right to confidentiality and authorize disclosure to the Recipient regarding these immigration benefits:
Sign the statement below authorizing DHS to disclose your information and/or records to
the Recipient.
STEP 3
I certify under penalty of perjury that the information above is accurate. I authorize DHS, its components, offices, employees, contractors,
agents, and assignees, to disclose the information or records specified above to the Recipient. I understand this may include and is not
limited to reports, evaluations, and notes of any kind, contained in any record keeping system maintained by or on behalf of DHS; that
DHS retains the discretion to decide if particular records or information are within the scope of this Waiver; and that DHS has no control
over how the Recipient will use or disseminate my information. I agree to release and hold harmless DHS, its components, offices,
employees, contractors, agents, and assignees, from any and all claims of action or damages of any kind arising from, or in any way
connected to, the release or use of any information or records pursuant to this Waiver.
*Privacy Waiver is valid for 90 days from date of signature *Witness may not be the Recipient or employed by Recipient's employer
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PRIVACY WAIVER AUTHORIZING DISCLOSURE TO A THIRD PARTY
DEPARTMENT OF HOMELAND SECURITY
U.S. Immigration and Customs Enforcement
Identifying Data
(Date of Birth, etc.)
Alien File (A-File)
Immigration Case
Criminal History
Detention Information
Family Data
Criminal Case
Medical Information
Travel/Border Crossing
The following information/records (describe):
ALL information and/or Records Requested by the Recipient
Temporary Protected Status (TPS)
Asylum
(confidentially applies even if petition is denied)
Seasonal Agricultural Worker
T Visa (for trafficking victims)
Battered Spouse/Child
Seeking Hardship Waiver
U Visa (for victims of certain crimes)
Violence Against Women Act
(VAWA)
Your Signature:
Date:
Witness Name:
Witness Signature:
Explanation of Immigrant Benefits
If you have applied for or received any of the immigration benefits below, you may be legally entitled to confidentiality
regarding these benefits. An explanation of these benefits is provided below to help you identify whether you have
applied for such benefits. If you have applied for or received these benefits and you want DHS to share information about
these benefits with the Recipient, you must waive your confidentiality rights by checking the appropriate boxes in Step 2
of this form (reverse). You are not required to waive confidentiality regarding these benefits; however, if you do not waive
these rights DHS may be unable to disclose to the Recipient some or all of the information you identified above.
Temporary Protected Status (TPS) - 8 U.S.C. § 1254a(c)(6). TPS is for foreign nationals currently residing in the U.S.
whose homeland conditions are recognized by the U.S. government as being temporarily unsafe or overly dangerous to
return to (e.g., war, earthquake, flood, drought, or other extraordinary and temporary conditions). ICE may disclose
information related to TPS to a third party with the consent of the alien.
T Visas and U Visas - Public Law 106-386, Section 701(c)(1)(C). A T visa allows certain victims of human trafficking to
remain in the United States for a period of time. A U visa allows certain victims of crimes to remain in the United States
for a period of time. ICE may disclose information related to T and U visas to third parties with the consent of the alien.
Legalization Claims, including Seasonal Agricultural Worker (SAW) Claims - 8 U.S.C. § 1255a(c)(4) and (5) and
8 U.S.C. § 1160(b)(5) and (6). Individuals who have applied for legalization, including those individuals employed in
agricultural work of a seasonal or temporary nature who have made SAW Claims, may permit ICE to disclose information
related to their claim to a third party with the individual's consent.
Battered Spouse or Child Information - 8 U.S.C. § 1186a(c)(4)(C). This provision applies to a battered alien or child who
has applied for a hardship waiver from removal under the INA. ICE may disclose information the alien provided to ICE in
support his or her request for waiver to a third party with consent of the alien.
Information Relating to Violence Against Women Act (VAWA) Claimants - 8 U.S.C. § 1367(a)(2). This provision applies
to a person who has filed a claim under the VAWA. ICE may disclose information related to a person's claim to a third
party with the consent of the person.
Asylum Information - 8 C.F.R. § 208.6. This provision applies to individuals who have applied for asylum, and
confidentiality regarding the asylum claim applies even if the claim is ultimately denied. ICE may disclose information
related to an individual's asylum claim to a third party with the consent of the person.
ICE Form 60-001 (2/11)
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Revocation of Privacy Waiver
This Privacy Waiver is valid for 90 days from the date of signature unless you have otherwise specified on this form. You
may revoke this Privacy Waiver at any time by contacting the ICE Privacy Office (202-732-3300 or [email protected]
)
or the relevant ICE office handing this matter or case. Certain information about you may be requested to confirm your
identity and you may be asked to revoke the waiver in writing.
