Form G-639 Freedom of Information/Privacy Act Request

Freedom of Information/Privacy Act Request
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form G-639
OMB No. 1615-0102
Expires 01/31/2015

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.

Part 1. Type of Request

Requestor's Contact Information

Select only one box.

4.

Requestor's Daytime Telephone Number

5.

Requestor's Mobile Telephone Number (if any)

6.

Requestor's Email Address (if any)

NOTE: If you are filing this request on behalf of another
individual, respond as it would apply to that individual.

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1.a.

Freedom of Information Act (FOIA)

1.b.

Privacy Act (PA)

1.c.

Amendment of Record (PA only)

Part 2. Requestor Information
1.

Are you the Subject of Record for this request?
Yes

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 Mailing Address

7.a. Requestor's Signature

3.b. Street Number
and Name
Ste.

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.
1.

3.a. In Care Of Name (if any)

Apt.

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.)

Part 3. Description of Records Requested

2.c. Middle Name

3.c.

No

7.b. Date of Signature (mm/dd/yyyy)

Requestor's Full Name
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

Requestor's Certification

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.)

Flr.

3.d. City or Town
3.e. State

3.f.

3.g. Province
3.h. Postal Code
3.i.

Country

ZIP Code

Full Name of the Subject of Record
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name

Form G-639 01/29/12 N

Page 1 of 4

Part 3. Description of Records Requested
(continued)
Other Names Used by the Subject of Record (include
nicknames, aliases, and maiden name, if applicable)

Family Member 2
10.a. Family Name
(Last Name)
10.b. Given Name
(First Name)
10.c. Middle Name

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

11.

Relationship

3.c. Middle Name

Parents' Names for the Subject of Record
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

Father

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12.a. Family Name
(Last Name)
12.b. Given Name
(First Name)

12.c. Middle Name
Mother

Other Information About the Subject of Record
5.

Form I-94 Number Arrival-Departure Record
►

6.

Alien Registration Number (A-Number) (if any)
► A-

7.

13.c. Middle Name

13.d. Maiden Name (if applicable)

Application, Petition, or Request Receipt Number
►

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.

13.a. Family Name
(Last Name)
13.b. Given Name
(First Name)

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

Relationship

Form G-639 01/29/12 N

Page 2 of 4

Part 4. Verification of Identity and Subject of
Record Consent (continued)

Signature and Notarized Affidavit or Declaration
of the Subject of Record

Mailing Address for the Subject of Record

Select only one box.
NOTE: 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.

2.a. In Care Of Name (if any)

2.b. Street Number
and Name
2.c.

Apt.

Ste.

Flr.

8.a.

2.d. City or Town
2.e. State

2.h. Postal Code
2.i.

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2.f.

2.g. Province

Country

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).

ZIP Code

Signature of Subject of Record

Date of Signature (mm/dd/yyyy)

Other Information for the Subject of Record
3.

Date of Birth (mm/dd/yyyy)

Subscribed and sworn to before me on this

4.

Country of Birth

day of

.

in the year

Daytime Telephone Number

Contact Information for the Subject of Record

Signature of Notary

Providing this information is optional.
5.

Daytime Telephone Number

6.

Mobile Telephone Number (if any)

7.

Email Address (if any)

My Commission Expires on

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

Date of Signature (mm/dd/yyyy)
8.c. Deceased Subject of Record (NOTE: You MUST attach
an obituary, death certificate, or other proof of death.)

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Page 3 of 4

5.a. Page Number

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)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

5.b. Part Number

5.c. Item Number

5.d.

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Alien Registration Number (A-Number) (if any)
► A-

3.a. Page Number

3.b. Part Number

3.d.

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

6.d.

4.a. Page Number

4.b. Part Number

4.c. Item Number

4.d.

7.a. Requestor's Signature (or Subject of Record's Signature if
you are filing this request for yourself)

7.b. Date of Signature (mm/dd/yyyy)

Form G-639 01/29/12 N

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