Privacy Waiver Authorizing Disclosure to a Third Party Translations: Arabic French Haitian Creole Hindi Portuguese Punjabi Russian Spanish Turkish

• Legal Form Number: 60-001
• Section: U.S. Immigration and Customs Enforcement
• Issuer: U.S. Immigration and Customs Enforcement

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 (12/22)

OR

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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DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement

PRIVACY WAIVER AUTHORIZING DISCLOSURE TO A THIRD PARTY

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)

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: