Form TOC Nonsubstantive Changes

TABLE OF CHANGES – FORM

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

OMB Number: 1615-0102

12/11/2014

Reason for Revision: Operational, USCIS standard formatting, and plain language updates

Current Section and Page Number	Current Text	Proposed Text
Page 1	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.	[Page 1] NOTE: Use of this request is optional. Any written format for a Freedom of Information or Privacy Act request is acceptable. START HERE - Type or print in black ink.
Page 1, 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: [Fillable Field]	[Page 1] Part 1. Type of Request Select only one box. NOTE: If you are filing this request on behalf of another individual, respond as it would apply to that individual. 1.a. Freedom of Information Act (FOIA) [delete] 1.b. Privacy Act (PA) 1.c. Amendment of Record (PA only) [delete]
Page 2, 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.) Daytime Telephone E-mail Address Address (Street Number and Name) Apt. Number City State Zip Code	[Page 1] Part 2. Requestor Information 1. Are you the Subject of Record for this request? Yes/No If you answered “No” to Item Number 1., provide the information requested in Part 2. If you answered “Yes” to Item Number 1., skip to Part 3. Requestor’s Full Name 2.a. Family Name (Last Name) 2.b. First Name (Given Name) 2.c. Middle Name [moved below] [moved below] Requestor’s Mailing Address 3.a. In Care Of Name 3.b. Street Number and Name 3.c. Apt./Ste./Flr. [Fillable Field] 3.d. City or Town 3.e. State 3.f. ZIP Code 3.g. Province 3.h. Postal Code 3.i. Country Requestor’s Contact Information 4. Requestor’s Daytime Telephone Number 5. Requestor’s Mobile Telephone Number (if any) 6. Requestor’s Email Address (if any) Requestor’s Certification By my signature, I consent to pay all costs incurred for search, duplication, and review of documents up to $25. (See Form G-639 Instructions for more information.) 7.a. Requestor’s Signature 7.b. Date of Signature (mm/dd/yyyy)
Page 1, 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): [Fillable Field] 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.) [Fillable Field] Family Name (Last Name) Given Name (First Name) Middle Name 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)	[Page 1] Part 3. Description of Records Requested NOTE: While you are not required to respond to every item in Part 3., failure to provide complete and specific information may delay processing of your request or create an inability for U.S. Citizenship and Immigration Services (USCIS) to locate the records or information requested. [delete] [delete] 1. Purpose (Optional: You are not required to state the purpose of your request. However, providing this information may assist USCIS in locating the records needed to respond to your request.) [Fillable Field] Full Name of the Subject of Record 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name Other Names Used by the Subject of Record (include nicknames, aliases, and maiden name, if applicable) 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name Full Name of the Subject of Record at Time of Entry into the United States 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Other Information About the Subject of Record 5. Form I-94 Number Arrival-Departure Record 6. Alien Registration Number (A-Number) (if any) 7. Application, Petition, or Request Receipt Number [moved below] [moved below] Information About Family Members that May Appear on Requested Records For example, provide the requested information about a spouse or children. If you need extra space to complete this section, use the space provided in Part 5. Additional Information. Family Member 1 8.a. Family Name (Last Name) 8.b. Given Name (First Name) 8.c. Middle Name 9. Relationship Family Member 2 10.a. Family Name (Last Name) 10.b. Given Name (First Name) 10.c. Middle Name 11. Relationship Parents’ Names for the Subject of Record Father 12.a. Family Name (Last Name) 12.b. Given Name (First Name) 12.c. Middle Name Mother 13.a. Family Name (Last Name) 13.b. Given Name (First Name) 13.c. Middle Name 13.d. Maiden Name (if applicable) [Delete] [Delete]
Page 2, 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 Zip Code Date of Birth (mm/dd/yyyy) Place of Birth The Subject of Record must provide a signature under either a Notarized Affidavit of Identity or a Sworn Declaration Under Penalty of Perjury: [Ckbox] Notarized Affidavit of Identity Signature of Subject of Record Date (mm/dd/yyyy) Subscribed and sworn to before me this [Fillable Field] day of [Fillable Field] Telephone No. Signature of Notary My Commission Expires on OR [Ckbox] Sworn Declaration Under Penalty of Perjury Executed outside 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." Signature of Subject of Record Executed in the United States 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	[Page 2] Part 4. Verification of Identity and Subject of Record Consent NOTE: The information requested in Part 4. is REQUIRED. Complete all applicable Item Numbers. In addition, the Subject of Record must sign Part 4. of this request. Full Name of the Subject of Record 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name [moved below] [moved below] Mailing Address for the Subject of Record 2.a. In Care Of Name 2.b. Street Number and Name 2.c. Apt./Ste./Flr. [Fillable Field] 2.d. City or Town 2.e. State 2.f. ZIP Code 2.g. Province 2.h. Postal Code 2.i. Country Other Information for the Subject of Record 3. Date of Birth (mm/dd/yyyy) 4. Country of Birth Contact Information for the Subject of Record Providing this information is optional. 5. Daytime Telephone Number 6. Mobile Telephone Number (if any) 7. Email Address (if any) Signature and Notarized Affidavit or Declaration of the Subject of Record Select only one box. The Subject of Record MUST provide a signature in Item Number 8.a. Notarized Affidavit of Identity OR Item Number 8.b. Sworn Declaration Under Penalty of Perjury. If the Subject of Record is deceased, read Item Number 8.c. and attach proof of death. 8.a. Notarized Affidavit of Identity (Do NOT sign and date below until the notary public provides instructions to you.) By my signature, I consent to USCIS releasing the requested records to the requestor (if applicable) named in Part 2. I also consent to pay all costs incurred for search, duplication, and review of documents up to $25 (if filing this request for myself). Signature of Subject of Record [Blank Field] Date of Signature (mm/dd/yyyy) [Blank Field] Subscribed and sworn to before me on this [Blank Field] day of [Blank Field] in the year [Blank Field] Daytime Telephone Number [Blank Field] Signature of Notary [Blank Field] My Commission Expires on [Blank Field] 8.b. Declaration Under Penalty of Perjury By my signature, I consent to USCIS releasing the requested records to the requestor (if applicable) named in Part 2. I also consent to pay all costs incurred for search, duplication, and review of documents up to $25 (if filing this request for myself). I certify, swear, or affirm, under penalty of perjury under the laws of the United States of America, that the information in this request is complete, true, and correct. Signature of Subject of Record [Blank Field] Date of Signature (mm/dd/yyyy) [Blank Field] 8.c. Deceased Subject of Record (NOTE: You MUST attach an obituary, death certificate, or other proof of death.)
Page 2, 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.) [Fillable Field] 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)	[Deleted]
New		Part 5. Additional Information If you need extra space to provide any additional information within this request, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with your request or attach a separate sheet of paper. Type or print the name of the Subject of Record and his or her A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which the information refers; and sign and date each sheet. 1.a. Family Name (Last Name) [auto-populate] 1.b. Given Name (First Name) [auto-populate] 1.c. Middle Name [auto-populate] 2. A-Number (if any) [auto-populate] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Requestor’s Signature (or Subject of Record’s Signature if you are filing this request for yourself) 6.b. Date of Signature (mm/dd/yyyy)

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