Fillable Office of Congresswoman Eddie Bernice Johnson TX30 (US House of Representatives)

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Office of Congresswoman Eddie Bernice Johnson TX30 (US House of Representatives)

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Office of Congresswoman Eddie Bernice Johnson – TX30
USCIS PRIVACY ACT RELEASE FORM
Under the Privacy Act of 1974, federal agencies are prohibited from disclosing information from your files without
your written consent. By completing this form and signing the Privacy Act statement below, you authorize the federal
agency/agencies involved to disclose said information to U.S. Representative Eddie Bernice Johnson and/or members
of her staff. Said information will be kept confidential by them. You also affirm that this request for assistance is in no
way an attempt to evade or violate any federal, state, or local law.
Effective February 15, 2018, USCIS will only accept a privacy release that authorizes the release of information to a
specific congressional office. A notarized signature or a signature made under penalty of perjury by the subject of the
record is now required, even if outside the United States. Digital signatures are not acceptable. USCIS policy requires
that an original document contain a handwritten, ink signature, unless otherwise provided by regulation or form
instruction.
USCIS Privacy Form – Office of Congresswoman Eddie Bernice Johnson – TX30 Page 1 of 2
Petitioner/Applicant Information
NAME (Last)___________________________________ (First) _______________________________ (MI) _______
ADDRESS: __________________________________________ CITY __________________ ZIP: ___________
PHONE _________________________________ EMAIL: _________________________________________
ALIEN #: ________________________ DOB: ________________ COUNTRY OF BIRTH: _______________
Beneficiary Information
NAME (Last)___________________________________ (First) _______________________________ (MI) _______
ALIEN #: ________________________ DOB: ________________ COUNTRY OF BIRTH: ________________
USCIS Receipt/Tracking #: _________________________________
DATE OF FILING: ________________________ PLACE OF FILING: _______________________________
Form type(s) – check all that apply:
G-639 I-90 I-129 I-129F I-130 I-131 I-140 I-212 I-290B I-360
I-485 I-526 I-539 I-589 I-590 I-600A I-600 I-601 I-612 I-690
I-730 I-751 I-765 I-821 I-824 I-829 I-914 (Supplement A, B, or C)
I-918 I-924 I-929 N-400 N-600 N-565 N-644 Other:
Brief Description of Issue:
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
USCIS Privacy Form – Office of Congresswoman Eddie Bernice Johnson – TX30 Page 2 of 2
_____________________________________________ _______________________________
Staff Member Name (print) Staff Phone
_____________________________________________
Staff Email Address
Section below to be completed by the person who is the subject of the records:
I certify, under penalty of perjury, that 1) I provided or authorized all of the information in this privacy release
and any document submitted with it; 2) I reviewed and understand all of the information contained in my
privacy release and submitted with it; and 3) all of this information is complete, true, and correct.
I, (print your name) ________________________________________, authorize USCIS to release information
contained in my USCIS records as relevant to checking my case status, and to the extent permitted by law, to
Representative Eddie Bernice Johnson and the Member’s staff.
___________________________________________ _____________________________
Petitioner/Applicant Signature Date
STATE OF TEXAS, COUNTY OF _____________________________
Before me, _______________________________ (insert the name and character of the officer), on this day personally
appeared _______________________________________________, known to me (or proved to me on the oath of)
______________________ (description of identity card or other document) to be the person whose name is subscribed
to the foregoing instrument and acknowledged to me that he/she executed the same for the purposes and
consideration therein expressed.
(Seal)
Given under my hand and seal of office this ______ day of _________________, 20____.
_________________________________________
(Notary's Signature) Notary Public, State of Texas
PLEASE RETURN THE COMPLETED FORM BY MAIL, FAX, OR IN PERSON TO:
Congresswoman Eddie Bernice Johnson
District Office
1825 Market Center Boulevard, Suite 440
Dallas, Texas 75207
(214) 922-8885 OFFICE ~ (214) 922-7028 FAX
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Office of Congresswoman Eddie Bernice Johnson TX30 (US House of Representatives)

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Completed 30 March 2021

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