Attachment D ORR Notice of Attorney Representation (Form L-3).pdf

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Notice of Attorney Representation Notice of Attorney Representation C:\Users\shannon.herboldshei\Desktop\HHS Seal.gif L-3 | Version 1 06/27/2022 L-3 | Version 1 Revised 06/27/2022 Administration for Children & Families Office of Refugee Resettlement Administration for Children & Families Office of Refugee Resettlement Page of THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow attorneys of record for UC to notify ORR of the purpose of their legal representation and the representation time frame so that they may receive case updates and request their client's records. Public reporting burden for this collection of information is estimated to average 0.25 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 UCPolicy@acf.hhs.gov.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow attorneys of record for UC to notify ORR of the purpose of their legal representation and the representation time frame so that they may receive case updates and request their client's records. Public reporting burden for this collection of information is estimated to average 0.25 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 UCPolicy@acf.hhs.gov.

OMB 0970-0565 [valid through 11/30/2024] OMB 0970-0565 [valid through 11/30/2024] Notice of Attorney Representation Office of Refugee Resettlement Notice of Attorney Representation Office of Refugee Resettlement L-3 | Version 1 06/27/2022 L-3 | Version 1 Revised 06/27/2022 Page of Attorneys of record for unaccompanied children (UC) in ORR care must submit a completed copy of this form to the UC's case manager. The attorney identified on this form will be provided updates on the UC's case for the duration of representation as noted below. A completed copy of this form is also required to receive a copy of the UC's case file.

Attorneys of record for unaccompanied children (UC) in ORR care must submit a completed copy of this form to the UC's case manager. The attorney identified on this form will be provided updates on the UC's case for the duration of representation as noted below. A completed copy of this form is also required to receive a copy of the UC's case file.

Section A: Information About the Attorney or Accredited Representative Section A: Information About the Attorney or Accredited Representative Section B: Eligibility Information the Attorney or Accredited Representative Section B: Eligibility Information the Attorney or Accredited Representative Check and complete all that apply. Use the +/- buttons to add or delete rows.

Check and complete all that apply. Use the plus and minus buttons to add or delete rows.

1. I am an attorney eligible to practice law in, and a member of good standing of, the bar of the highest courts of the following states, possessions, territories, commonwealths, or the District of Columbia.

Licensing Authority Licensing Authority Bar Number (if applicable) Bar Number (if applicable) Are you subject to any order suspending, enjoining, restraining, disbarring, or other wise restricting your practice of law?

Are you subject to any order suspending, enjoining, restraining, disbarring, or other wise restricting your practice of law? Use the up arrow and down arrow keys to move through the list. Pressing the tab key will select the item in the list.

2. I am an accredited representative of the following qualified nonprofit religious, charitable, social service, or other similar organization established in the United States and recognized by the Department of Justice in accordance with 8 CFR part 1292.

Name of Recognized Organization Name of Recognized Organization Date of Accreditation Date of Accreditation

3. I am associated with the attorney or accredited representative of record who previously filed this form in this case, and my appearance as an attorney or accredited representative for a limited purpose is at his or her request.

4. I am a law student or law graduate working under the direct supervision of the attorney or accredited representative of record on this form in accordance with the requirements in 8 CFR 1292.1(a)(2).

Section C: Notice of Appearance as Attorney or Accredited Representative Section C: Notice of Appearance as Attorney or Accredited Representative

1. Information About Client

1. Information About Client

2. I will be representing my client in the below capacity. Check all that apply.

2. I will be representing my client in the below capacity. Check all that apply.

3. I will be representing my client until the following event or date occurs. Check one.

3. I will be representing my client until the following event or date occurs. Check one.

3. I will be representing my client until the following event or date occurs. Check one. Use the up arrow and down arrow keys to move through the list. Pressing the tab key will select the item in the list.

Section D: UC's Consent to Representation Section D: UC's Consent to Representation I have requested the representation of and consented to being represented by the attorney or accredited representative name in Section A of this form. According to the Privacy Act of 1974 and ORR policy, I also consent to the disclosure to the named attorney or accredited representative of records pertaining to me that appear in any system of records of ORR.

I have requested the representation of and consented to being represented by the attorney or accredited representative name in Section A of this form. According to the Privacy Act of 1974 and ORR policy, I also consent to the disclosure to the named attorney or accredited representative of records pertaining to me that appear in any system of records of ORR.

Section E: Signature of Attorney or Accredited Representative Section E: Signature of Attorney or Accredited Representative I have read and agree to abide by the regulations and conditions contained in 8 CFR 103.2 and 292 governing appearances and representation of UC and the ORR policies governing representation of UAC. I will represent the UC in accordance with the professional ethics required by my licensing bureau. I will not unreasonably interfere with or obstruct ORR from performing its charged duties, including but not limited to releasing the UC from ORR custody. I declare under penalty of perjury under the laws of the United States that the information I have provided on this form is true and correct.

I have read and agree to abide by the regulations and conditions contained in 8 CFR 103.2 and 292 governing appearances and representation of UC and the ORR policies governing representation of UAC. I will represent the UC in accordance with the professional ethics required by my licensing bureau. I will not unreasonably interfere with or obstruct ORR from performing its charged duties, including but not limited to releasing the UC from ORR custody. I declare under penalty of perjury under the laws of the United States that the information I have provided on this form is true and correct.

Attorney or Accredited Representative Attorney or Accredited Representative Law Student or Law Graduate Law Student or Law Graduate 1.0 2/2/2018 Shannon Herboldsheimer Sponsor Check Request Form 2/2/2018