I-783 (Rev. 04-02-2014) OMB-1110-0052
PRIVACY ACT STATEMENT
The FBI’s acquisition, retention, and sharing of information submitted on this form is generally authorized under 28 USC 534 and 28 CFR 16.30-16.34. The purpose for requesting this information from you is to provide the
FBI with a minimum of identifying data to permit an accurate and timely search of identity history identification records. Providing this information (including your Social Security Account Number) is voluntary; however,
failure to provide the information may affect the completion of your request. The information reported on this form may be disclosed pursuant to your consent, and may also be disclosed by the FBI without your consent pursuant
to the Privacy Act of 1974 and all applicable routine uses. Under the Paperwork Reduction Act, you are not required to complete this form unless it contains a valid OMB control number. The form takes approximately 3 minutes
to complete.
Applicant Information * Denotes Required Fields
*Last Name *First Name
Middle Name 1 Middle Name 2
*Date of Birth:
*Place of Birth: U.S. Citizen or Legal Permanent Resident:
Yes No
*Country of Citizenship: Country of Residence: Prisoner Number (if applicable):
*Last Four Digits of Social Security Number:
*Height:
*Weight:
*Hair
(please check appropriate box):
Bald Black Blonde/Strawberry Blue Brown Gray Green Orange Pink
Purple Red/Auburn Sandy Unknown White
*Eyes (please check appropriate box):
Black Blue Brown Gray Green Hazel Maroon Multicolored Pink Unknown
Applicant Home Address
*Address
*City
*State
*Postal (Zip) Code
*Country
Phone Number
E-Mail
Mail Results to Address
C/O
ATTN
Address
City State
Postal (Zip) Code
Country
Phone Number (if different from above)
Payment Enclosed: (please check appropriate box)
CERTIFIED CHECK MONEY ORDER CREDIT CARD FORM
Reason for Request:
Personal review Challenge information on your record Adoption of a child in the U.S.
International adoption Live, work, or travel in a foreign country Other
* APPLICANT SIGNATURE DATE
Mail
the signed applicant information form, fingerprint card, and payment of $18 U.S. dollars to the following address:
FBI CJIS Division – Summary Request
1000 Custer Hollow Road
Clarksburg, West Virginia 26306
You may request a copy of your own Identity History Summary to review it
or obtain a change, correction, or an update to the summary.
