Fillable G-639 Freedom of Information/Privacy Act Request

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G-639 Freedom of Information/Privacy Act Request

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Country of origin: US
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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form G-639 06/20/19 Page 1 of 5
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 06/30/2022
START HERE - Type or print in black ink.►
Part 1. Type of Request
1.a.
1.b.
Freedom of Information Act (FOIA)/Privacy Act (PA)
Amendment of Record (PA only)
Part 2. Requestor Information
Representative Role to the Subject of Record
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 "Yes" to Item Number 1., skip to Part 3. If
you answered "No" to Item Number 1., provide the information
requested in Part 2., Item Numbers 2.a. - 3.c.
1.
NoYes
Requestor's Mailing Address
City or Town5.d.
Street Number
and Name
5.b.
5.c. Ste. Flr.Apt.
In Care Of Name (if any)5.a.
5.g.
5.i.
Province
Country
5.h.
Postal Code
ZIP Code5.f.State
5.e.
Select your representative role to the Subject of the Record.
Select the appropriate box to provide further information
regarding your representative role to the Subject of the Record.
2.a.
2.c.
A Family Member
An Accredited Representative of a Qualified
Organization
2.b.
An Attorney
3.a.
3.c.
I am requesting information on behalf of someone for
whom I have power of attorney.
I am requesting information on behalf of someone
who is deceased.
3.b.
I am requesting information on behalf of my child or
a minor I have guardianship over.
(USPS ZIP Code Lookup)
6. Requestor's Daytime Telephone Number
Requestor's Contact Information
Requestor's Mobile Telephone Number (if any)7.
Requestor's Email Address (if any)8.
By my signature, I consent to pay all costs incurred for search,
duplication, and review of documents up to $25. (See the What
Is the Filing Fee section in the Form G-639 Instructions for
more information.)
Requestor's Signature
Requestor's Certification
9.a.
9.b.
(mm/dd/yyyy)Date of Signature
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. However, using this form can help ensure we
have the appropriate information to handle your request.
4.b.
4.c.
4.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Requestor's Full Name
Form G-639 06/20/19 Page 2 of 5
Part 3. Description of Records Requested
While you are not required to respond to every Item Number in
Part 3., failure to provide complete and specific information may
delay processing of your request or prevent U.S. Citizenship and
Immigration Services (USCIS) from locating the records or
information requested.
1.
State the purpose of your request.
NOTE: This field is optional. However, providing this
information may assist USCIS in locating the records and
information 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
Other Names Used by the Subject of Record (if any)
Full Name of the Subject of Record at Time of
Entry into the United States
Provide all other names the Subject of Record has ever used,
including aliases, maiden name, and nicknames. If you need
extra space to complete this section, use the space provided in
Part 6. Additional Information.
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
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
5.a.
5.c.
5.b.
Other Information About the Subject of Record
►
►
6.a.
Form I-94 Arrival-Departure Record Number
Passport or Travel Document Number
7. Alien Registration Number (A-Number) (if any)
9. Application or Petition Receipt Number
A-
6.b.
►
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 6. Additional Information.
Family Member 1
10.b.
10.c.
10.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Relationship
11.
8.
►
USCIS Online Account Number (if any)
13.
Relationship
Parents' Names for the Subject of Record
Father
14.b.
14.c.
14.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
12.a.
12.c.
12.b.
Family Member 2
Form G-639 06/20/19 Page 3 of 5
Part 3. Description of Records Requested
(continued)
15.d. Maiden Name (if applicable)
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
15.a.
15.c.
15.b.
Mother
16.
Describe the records you are seeking. If you need
additional space, use the space provided in Part 6.
Additional Information.
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
Provide the information requested in Item Numbers 1.a. - 7.
In addition, the Subject of Record MUST sign in Item
Numbers 8.a. - 8.c.
Full Name of the Subject of Record
Other Information for the Subject of Record
Country of Birth
3.
2. Date of Birth (mm/dd/yyyy)
Mailing Address for the Subject of Record
4.d.
4.b.
4.c.
4.a.
4.g.
4.i.
4.h.
4.e.
City or Town
Street Number
and Name
Ste. Flr.
Apt.
In Care Of Name (if any)
Province
Country
Postal Code
ZIP Code4.f.State
Contact Information for the Subject of Record
5.
Mobile Telephone Number (if any)6.
Daytime Telephone Number
NOTE: Providing this information is optional.
Email Address (if any)7.
Form G-639 06/20/19 Page 4 of 5
Part 4. Verification of Identity and Subject of
Record Consent (continued)
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
.
Signature of the Subject of Record
NOTE: The Subject of Record MUST provide a signature in
Item Number 8.a. OR Item Number 8.b. If the Subject of
Record is deceased, select Item Number 8.c. and attach an
obituary, death certificate, or other 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. If filing this request on my own
behalf, I also consent to pay all costs incurred for
search, duplication, and review of documents up to
$25. (See the What Is the Filing Fee section in the
Form G-639 Instructions for more information.)
8.a.
Signature of Subject of Record
IMPORTANT: Do NOT sign and date below until
the notary public provides instructions to you.
Deceased Subject of Record 8.c.
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. If filing this request on my own
behalf, I also consent to pay all costs incurred for
search, duplication, and review of documents up to
$25. (See the What Is the Filing Fee section in the
Form G-639 Instructions for more information.)
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)
8.b.
Part 5. Processing Information
Indicate if any of these circumstances apply to your
request (Select all that apply).
Circumstances in which the lack of expedited
treatment could reasonably be expected to pose an
imminent threat to the life or physical safety of the
individual.
An urgency to inform the public about an actual or
alleged Federal government activity, if made by a
person primarily engaged in disseminating
information.
The loss of substantial due process rights.
A matter of widespread and exceptional media
interest in which there exists possible questions about
the government's integrity which affects public
confidence.
1.
Submit a certified, detailed statement regarding the basis for
your request with your Form G-639.
If you answered “Yes” to Item Number 2., submit a copy of
one of the following documents with your Form G-639: I-862,
Notice to Appear; Form I-122, Order to Show Cause; Form
I-863, Note of Referral to Immigration Judge, or submit a
written notice of continuation of a future scheduled hearing
before the immigration judge.
Do you have a pending Immigration Court hearing date?
2.
NoYes
Form G-639 06/20/19 Page 5 of 5
Part 6. 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 this request or attach a separate sheet
of paper. Type or print the Subject of Record's name 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
your answer refers; and sign and date each sheet.
1.b.
1.c.
1.a. Subject of Record's Family Name (Last Name)
Subject of Record's Given Name (First Name)
Subject of Record's Middle Name
►
Subject of Record's 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.
7.b. 7.c.Page Number
Part Number Item Number
7.a.
7.d.
6.d.
6.a.
Item NumberPart NumberPage Number 5.c.5.b.
Item NumberPart NumberPage Number 6.c.6.b.
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G-639 Freedom of InformationPrivacy Act Request

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Completed 6 November 2019

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