Form G-639 Freedom of Information/Privacy Act Request

OMB No. 1615-0102; Expires 10/31/11

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. NOTE: If you are filing this request for records on behalf of another
individual, please respond to Number 1 as it would apply to that individual.)
Freedom of Information Act (FOIA): I am not a U.S. citizen/Lawful Permanent Resident and I am requesting my own records.
Freedom of Information Act (FOIA): I am a U.S. citizen/Lawful Permanent Resident and I am requesting documents other than
my own records.
Privacy Act (PA): I am a U.S. citizen/Lawful Permanent Resident and I am requesting my own records.
Amendment of Record (PA only): I am a U.S. citizen/Lawful Permanent Resident and I am requesting amendment of my own
records.
Other:

2. Description of Record(s) Requested:
NOTE: While you are not required to respond to all items in Number 2, failure to provide complete and specific information as
requested may result in a delay in processing or an inability to locate the record(s) or information requested.
Complete Alien File (A-File)
Other (please specify):

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

Family Name (Last Name)

Given Name (First Name)

Other Names Used (if any)
Alien Registration Number (A#)

Middle Name

Name at time of entry into the U.S.
Petition or Claim Receipt #

Country of Birth

I-94 Admission #
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
Father's Name: Given Name (First Name)

Middle Name

Manner of Entry (Air, Sea, Land)

Relationship

Family Name (Last Name)

Mother's Name: Given Name (First Name) Middle Name
Country of Origin (Place of Departure)

Family Name (Last Name)

Family Name (Last Name, including Maiden Name)

Port of Entry Into the U.S.

Date of Entry (mm/dd/yyyy)

Mode of Travel (Name of Carrier)

Form G-639 (08/23/11) Y

3. Subject of Record Consent to Release Information (Must be signed by the subject of record(s) requested.)
By my signature, I consent to allow USCIS to release to the requester named in Number 5 (Check applicable box):
All of my records

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

Print Name of Subject of Record
Signature of Subject of Record

Date (mm/dd/yyyy)

Deceased Subject - Proof of death must be attached (Obituary, Death Certificate, or other proof of death required)

4. Verification of Identity (Required; Fill out all that apply.)
Name of Subject of Record (First, Middle, Last)

Daytime Telephone

E-mail Address

Address (Street Number and Name)

Apt. Number

City

State

Date of Birth (mm/dd/yyyy)

Place of Birth

Zip Code

The Subject of Record must provide a signature under either a Notarized Affidavit of Identity or a Sworn Declaration Under
Penalty of Perjury:
Notarized Affidavit of Identity
Signature of Subject of Record
Subscribed and sworn to before me this

Date (mm/dd/yyyy)
day of

Signature of Notary

Telephone No.
My Commission Expires on

Sworn Declaration Under Penalty of Perjury

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 of Subject of Record

Signature of Subject of Record

5. Requester Information
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:
Name of Requester (Fill out if different from the Subject of Record.)
Address (Street Number and Name)
City

Daytime Telephone

E-mail Address
Apt. Number

State

Zip Code

Form G-639 (08/23/11) Y Page 2