Form G-639 Freedom of Information/Privacy Act Request

OMB No. 1615-0102; Expires 10/31/10

Form G-639, Freedom of
Information/Privacy Act Request

Department of Homeland Security
U.S. Citizenship and Immigration Services

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
*Other Names Used (if any)

(Continued)
* Name at time of entry into the U.S.

I-94 Admission #
*Date of Birth (mm/dd/yyyy)

*Alien Registration Number (A#) * Petition or Claim Receipt # * Country of Birth

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)

Date of Entry (mm/dd/yyyy)

Port of Entry Into the U.S.

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

Other (Specify):

Notarized Affidavit of Identity

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

Signature of Notary

in the year
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,
verify, or state) under penalty of perjury under the laws of the
United States of America that the foregoing is true and correct.

If executed within the United States, its territories, possessions,
or commonwealths: ''I declare (certify, verify, or state) under
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