Copyright © 2017 eForms. All Rights Reserved.
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: XXX-XX-______
*Height ___________________ *Weight ___________________
*Hair (please check appropriate box):
- Bald Black - Blonde/Strawberry - Blue - Brown - Gray - Green
- Orange - Pink - Purple - 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 _________________________________________
Copyright © 2017 eForms. All Rights Reserved.
Mail Results to Address
C/O ________________________ ATTN __________________________________________
Address ___________________________________________________________________
*City ______________________ *State________________ Postal Zip Code ____________
*Country ______________________ Phone Number ______________________
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.
click to sign
signature
click to edit
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