Official Federal Forms > US Citizenship And Immigration Services
Freedom Of Information-Privacy Act Request G-639 - Official Federal Forms
| Freedom Of Information-Privacy Act Request Form. This is a national form and can be used in US Citizenship And Immigration Services . |
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OMB No. 1615-0102; Expires 01/31/2015 Department of Homeland Security U.S. Citizenship and Immigration Services Form G-639, Freedom of Information/Privacy Act Request NOTE: Use of this form is optional. Any written format for a Freedom of Information or Privacy Act request is acceptable. START HERE - Type or print in black ink. Read instructions before completing this form. 1. Type of Request (Check appropriate box. NOTE: If you are filing this request for records on behalf of another individual, please respond to Number 1 as it would apply to that individual.) Freedom of Information Act (FOIA): I am not a U.S. citizen/Lawful Permanent Resident and I am requesting my own records. Freedom of Information Act (FOIA): I am a U.S. citizen/Lawful Permanent Resident and I am requesting documents other than my own records. Privacy Act (PA): I am a U.S. citizen/Lawful Permanent Resident and I am requesting my own records. Amendment of Record (PA only): I am a U.S. citizen/Lawful Permanent Resident and I am requesting amendment of my own records. Other: 2. Description of Record(s) Requested: NOTE: While you are not required to respond to all items in Number 2, failure to provide complete and specific information as requested may result in a delay in processing or an inability to locate the record(s) or information requested. Complete Alien File (A-File) Other (please specify): Purpose: (Optional: You are not required to state the purpose of your request. However, doing so may assist USCIS in locating the record(s) needed to respond to your request.) Family Name (Last Name) Other Names Used (if any) Alien Registration Number (A#) Given Name (First Name) Middle Name I-94 Admission # Date of Birth (mm/dd/yyyy) Name at time of entry into the U.S. Petition or Claim Receipt # Country of Birth Names of other family members that may appear on requested record(s) (i.e., spouse, daughter, son): Family Member's Name: Given Name (First Name) Middle Name Father's Name: Given Name (First Name) Middle Name Family Name (Last Name) Family Name (Last Name) Relationship Mother's Name: Given Name (First Name) Middle Name Country of Origin (Place of Departure) Manner of Entry (Air, Sea, Land) Port of Entry Into the U.S. Family Name (Last Name, including Maiden Name) Date of Entry (mm/dd/yyyy) Mode of Travel (Name of Carrier) Form G-639 (01/29/12) N Page 1 American LegalNet, Inc. www.FormsWorkFlow.com 3. Subject of Record Consent to Release Information (Must be signed by the subject of record(s) requested.) By my signature, I consent to allow USCIS to release to the requester named in Number 5 (Check applicable box): All of my records A portion of my records (If a portion, specify below what part, i.e., copy of application.) Print Name of Subject of Record Signature of Subject of Record Date (mm/dd/yyyy) Deceased Subject - Proof of death must be attached (Obituary, Death Certificate, or other proof of death required) 4. Verification of Identity (Required; Fill out all that apply.) Name of Subject of Record (First, Middle, Last) Address (Street Number and Name) City Date of Birth (mm/dd/yyyy) State Place of Birth Daytime Telephone E-mail Address Apt. Number Zip Code The Subject of Record must provide a signature under either a Notarized Affidavit of Identity or a Sworn Declaration Under Penalty of Perjury: Notarized Affidavit of Identity Signature of Subject of Record Subscribed and sworn to before me this Signature of Notary OR Sworn Declaration Under Penalty of Perjury day of Date (mm/dd/yyyy) Telephone No. My Commission Expires on Executed outside the United States If executed outside the United States: ''I declare (certify, verify, or state) under penalty of perjury under the laws of the United States of America that the foregoing is true and correct." Signature of Subject of Record Executed in the United States If executed within the United States, its territories, possessions, or commonwealths: ''I declare (certify, verify, or state) under penalty of perjury that the foregoing is true and correct." Signature of Subject of Record 5. Requester Information By my signature, I consent to pay all costs incurred for search, duplication and review of materials up to $25 (See instructions) Signature of Requester: Name of Requester (Fill out if different from the Subject of Record.) Address (Street Number and Name) City State Daytime Telephone E-mail Address Apt. Number Zip Code Form G-639 (01/29/12) N Page 2 American LegalNet, Inc. www.FormsWorkFlow.com
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