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    G 639

    Uploaded by

    sekrish
    This document is a Freedom of Information Act/Privacy Act request form from the U.S. Citizenship and Immigration Services. The form requests information to identify the requester, the subject of the requested records if different from the requester, details about the information being sought, and verification of identity. Completing the form allows the agency to search for and release applicable records to the requester while protecting private information through verification and consent procedures.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    G 639

    Uploaded by

    sekrish
    106 views2 pages
    This document is a Freedom of Information Act/Privacy Act request form from the U.S. Citizenship and Immigration Services. The form requests information to identify the requester, the subject of the requested records if different from the requester, details about the information being sought, and verification of identity. Completing the form allows the agency to search for and release applicable records to the requester while protecting private information through verification and consent procedures.

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    g-639

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    This document is a Freedom of Information Act/Privacy Act request form from the U.S. Citizenship and Immigration Services. The form requests information to identify the requester, the subject of the requested records if different from the requester, details about the information being sought, and verification of identity. Completing the form allows the agency to search for and release applicable records to the requester while protecting private information through verification and consent procedures.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    106 views2 pages

    G 639

    Uploaded by

    sekrish
    This document is a Freedom of Information Act/Privacy Act request form from the U.S. Citizenship and Immigration Services. The form requests information to identify the requester, the subject of the requested records if different from the requester, details about the information being sought, and verification of identity. Completing the form allows the agency to search for and release applicable records to the requester while protecting private information through verification and consent procedures.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    OMB No.

    1615-0102; Expires 10/31/10

    Department of Homeland Security


    Form G-639, Freedom of
    U.S. Citizenship and Immigration Services Information/Privacy Act Request

    NOTE: Use of this form is optional. Any written format for a Freedom of Information or Privacy Act request is acceptable.
    START HERE - Type or print in black ink. Read instructions before completing this form.
    1. Type of Request (Check appropriate box)
    Freedom of Information Act (FOIA) (Complete all items except Number 6.)
    Privacy Act (PA) (Number 6 must be completed in addition to all other applicable items.)
    Amendment of Record (PA only) (Number 5 must be completed in addition to all other applicable items.)

    2. Requester Information
    Name of Requester (Last, First, and Middle Names) Date (mm/dd/yyyy) Daytime Telephone

    Address (Street Number and Name) Apt. Number

    City State Zip Code

    By my signature, I consent to pay all costs incurred for search, duplication and review of materials up to $25 (See instructions)
    Signature of requester:
    Deceased Subject - Proof of death must be attached (Obituary, Death Certificate, or other proof of death required)

    3. Consent to Release Information (Complete if person is different from requester.) (Numbers 7 and 8 must be completed.)
    Print Name of Person/Record Subject Giving Consent Signature of Person Giving Consent (Original signature required)

    By my signature, I consent to allow the requester named in Number 2 above to review (Check applicable box):

    All of my records A portion of my records (If a portion, specify below what part, i.e., copy of application.)

    (Consent is required for records of U. S. citizens (USC) and lawful permanent residents (LPR).)

    4. Information Needed to Search for Record(s)


    Identify the documents, records, or information you are seeking. Be as specific as possible.

    Purpose: (Optional: You are not required to state the purpose of your request. However, doing so may assist USCIS in locating the
    records needed to respond to your request.)

    5. Data Needed on Subject of Record (Note: Items marked with an asterisk (*) must be provided if known.)
    *Family Name (Last Name) Given Name (First Name) Middle Name

    Form G-639 (02/04/09) N


    5. Data Needed on Subject of Record (Continued)
    *Other Names Used (if any) * Name at time of entry into the U.S. I-94 Admission #

    *Alien Registration Number (A#) * Petition or Claim Receipt # * Country of Birth *Date of Birth (mm/dd/yyyy)

    Names of other family members that may appear on requested record(s) (i.e., spouse, daughter, son):
    *Family Member's Name: Given Name (First Name) Middle Name Family Name (Last Name) Relationship

    *Father's Name: Given Name (First Name) Middle Name Family Name (Last Name)

    *Mother's Name: Given Name (First Name) Middle Name Family Name (Last Name) (including Maiden Name)

    Country of Origin (Place of Departure) Port of Entry Into the U.S. Date of Entry (mm/dd/yyyy)

    Manner of Entry (Air, Sea, Land) Mode of Travel (Name of Carrier)

    6. Verification of Subject of Record's Identity (See instructions for explanation. Check one box.)
    In-Person With ID Notarized Affidavit of Identity Other (Specify):
    7. Signature of Subject of Record
    (Original signature required): Date (mm/dd/yyyy)
    Telephone No.

    8. Notary (Normally needed from persons who are the subject of the record sought or for a sworn declaration under
    penalty of perjury. See below.)
    Subscribed and sworn to before me this day of in the year

    Signature of Notary My Commission Expires on

    NOTE: If a declaration is provided in lieu of a notarized signature, it must state at a minimum the following (include notary seal or
    stamp in the appropriate space below):
    Executed outside the United States Executed in the United States
    If executed outside the United States: ''I declare (certify, If executed within the United States, its territories, possessions,
    verify, or state) under penalty of perjury under the laws of the or commonwealths: ''I declare (certify, verify, or state) under
    United States of America that the foregoing is true and correct. penalty of perjury that the foregoing is true and correct.

    Signature Signature

    Seal or Stamp Seal or Stamp

    Form G-639 (02/04/09) N Page 2

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