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Foia-request-form Freedom of Information/Privacy Act Request

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Form G-639 04/17/17 N Page 1 of 4
Freedom of Information/Privacy Act Request
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form G-639
OMB No. 1615-0102
Expires 04/30/2020
START HERE - Type or print in black ink.►
Part 1. Type of Request
NOTE: Use of this form is optional. USCIS accepts any written request, regardless of format, provided that the request complies
with the applicable requirements under the FOIA and the Privacy Act.
1.a.
1.b.
Freedom of Information Act (FOIA)/Privacy Act (PA)
Amendment of Record (PA only)
Part 2. Requestor Information
2.b.
2.c.
2.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Requestor's Full Name
By my signature, I consent to pay all costs incurred for search,
duplication, and review of documents up to $25. (See Form
G-639 Instructions for more information.)
Requestor's Signature
Requestor's Certification
7.a.
7.b.
(mm/dd/yyyy)Date of Signature
Select only one box.
NOTE: If you are filing this request on behalf of another
individual, respond as it would apply to that individual.
Are you the Subject of Record for this request?
If you answered "No" to Item Number 1., provide the
information requested in Part 2. If you answered "Yes" to
Item Number 1., skip to Part 3.
1.
NoYes
4. Requestor's Daytime Telephone Number
Requestor's Contact Information
Requestor's Mobile Telephone Number (if any)5.
Requestor's Email Address (if any)6.
Part 3. Description of Records Requested
NOTE: While you are not required to respond to every item in
Part 3., failure to provide complete and specific information
may delay processing of your request or create an inability for
U.S. Citizenship and Immigration Services (USCIS) to locate
the records or information requested.
Requestor's Mailing Address
City or Town3.d.
Street Number
and Name
3.b.
3.c. Apt.
Flr.Ste.
In Care Of Name (if any)3.a.
1.
Purpose (Optional: You are not required to state the
purpose of your request. However, providing this
information may assist USCIS in locating the records
needed to respond to your request.)
Full Name of the Subject of Record
2.b.
2.c.
2.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
3.g.
3.i.
Province
Country
3.h.
Postal Code
ZIP Code
3.f.
State
3.e.
Form G-639 04/17/17 N Page 2 of 4
Part 3. Description of Records Requested
(continued)
Other Names Used by the Subject of Record (if any)
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
4.a.
4.c.
4.b.
3.b.
3.c.
3.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Full Name of the Subject of Record at Time of
Entry into the United States
Other Information About the Subject of Record
►
►
5. Form I-94 Number Arrival-Departure Record
Alien Registration Number (A-Number) (if any)
8. Application, Petition, or Request Receipt Number
A-
6.
►
12.
Relationship
Parents' Names for the Subject of Record
Father
13.b.
13.c.
13.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
14.d. Maiden Name (if applicable)
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
14.a.
14.c.
14.b.
Mother
Information About Family Members that May
Appear on Requested Records
For example, provide the requested information about a spouse
or children. If you need extra space to complete this section,
use the space provided in Part 5. Additional Information.
Family Member 1
9.b.
9.c.
9.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Relationship
10.
Part 4. Verification of Identity and Subject of
Record Consent
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
NOTE: Complete all applicable Item Numbers. In addition,
the Subject of Record MUST sign Part 4. of this request.
Full Name of the Subject of Record
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
11.a.
11.c.
11.b.
Family Member 2
Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 5.
Additional Information.
7.
►
USCIS Online Account Number (if any)
15. Description of Records Sought.
Provide a description of the records you are seeking. If
you need additional space, use the space provided in Part
5. Additional Information.
Form G-639 04/17/17 N Page 3 of 4
Part 4. Verification of Identity and Subject of
Record Consent (continued)
Contact Information for the Subject of Record
5.
Mobile Telephone Number (if any)6.
Daytime Telephone Number
Providing this information is optional.
Date of Signature (mm/dd/yyyy)
Subscribed and sworn to before me on this
day of
in the year
Daytime Telephone Number
My Commission Expires on (mm/dd/yyyy)
Signature of Notary
Declaration Under Penalty of Perjury
By my signature, I consent to USCIS releasing the
requested records to the requestor (if applicable)
named in Part 2. I also consent to pay all costs
incurred for search, duplication, and review of
documents up to $25 (if filing this request for myself).
I certify, swear, or affirm, under penalty of perjury
under the laws of the United States of America, that
the information in this request is complete, true, and
correct.
Signature of Subject of Record
Date of Signature (mm/dd/yyyy)
Email Address (if any)7.
Deceased Subject of Record
.
8.b.
8.c.
Other Information for the Subject of Record
Country of Birth
4.
Signature and Notarized Affidavit or Declaration
of the Subject of Record
NOTE: The Subject of Record MUST provide a signature in
Item Number 8.a. Notarized Affidavit of Identity OR Item
Number 8.b. Declaration Under Penalty of Perjury. If the
Subject of Record is deceased, read Item Number 8.c.
Deceased Subject of Record and attach proof of death.
Select only one box.
Notarized Affidavit of Identity
By my signature, I consent to USCIS releasing the
requested records to the requestor (if applicable)
named in Part 2. I also consent to pay all costs
incurred for search, duplication, and review of
documents up to $25 (if filing this request for myself).
8.a.
Signature of Subject of Record
3. Date of Birth
(mm/dd/yyyy)
Mailing Address for the Subject of Record
City or Town2.d.
Street Number
and Name
2.b.
2.c. Apt.
Flr.Ste.
In Care Of Name (if any)2.a.
2.g.
2.i.
Province
Country
2.h.
Postal Code
ZIP Code
2.f.
State
2.e.
(Do NOT sign and date below until the notary public
provides instructions to you.)
(NOTE: You MUST attach an obituary, death certificate,
or other proof of death.)
Form G-639 04/17/17 N Page 4 of 4
Part 5. Additional Information
If you need extra space to provide any additional information
within this request, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with your request or attach a separate sheet
of paper. Type or print the name of the Subject of Record and
his or her A-Number (if any) at the top of each sheet; indicate
the Page Number, Part Number, and Item Number to which
the information refers; and sign and date each sheet.
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
►
Alien Registration Number (A-Number) (if any)
A-
2.
3.d.
3.a. 3.b.
Item NumberPart NumberPage Number 4.c.4.b.
3.c.Page Number
Part Number Item Number
4.d.
4.a.
5.d.
5.a.
6.d.
6.a.
Item NumberPart NumberPage Number 5.c.5.b.
Item NumberPart NumberPage Number 6.c.6.b.
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Foia-request-form Freedom of InformationPrivacy Act Request

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Completed 2 July 2020

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