TABLE OF CHANGES – FORM
Form I-639, Freedom of Information/Privacy Act Request
2/28/2017 (2)
Reason for Revision: Working Group edits and Standard Language updates
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Current Page Number and Section |
Current Text |
Proposed Text |
Page 1, Part 1. Type of Request |
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 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) 1.b. Privacy Act (PA) 1.c. Amendment of Record (PA only) |
[Page 1]
NOTE: Use of this form is optional. USCIS accepts any written request, regardless of format, provided that the request complies with the applicable requirements under the FOIA and the Privacy Act. START HERE - Type or print in black ink. 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)/Privacy Act (PA) 1.b. Amendment of Record (PA only)
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Page 1, Part 2. Requestor Information |
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. Given Name (First Name)
2.c. Middle Name
Requestor's Mailing Address
3.a. In Care Of Name (if any)
3.b. Street Number and Name
3.c. Apt. Ste. Flr.
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)
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[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. Given Name (First Name)
2.c. Middle Name
Requestor's Mailing Address
3.a. In Care Of Name (if any)
3.b. Street Number and Name
3.c. Apt. Ste. Flr.
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)
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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.
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.)
Full Name of the Subject of Record 2.a. Family Name (Last Name)
2.b. Given Name (First Name)
2.c. Middle Name
Part 3. Description of Records Requested (continued)
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
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)
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[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.
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.)
Full Name of the Subject of Record 2.a. Family Name (Last Name)
2.b. Given Name (First Name)
2.c. Middle Name
[Page 2]
Part 3. Description of Records Requested (continued)
Other Names Used by the Subject of Record (if any)
Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 5. Additional Information.
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. USCIS Online Account Number (if any)
8. 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
9.a. Family Name (Last Name)
9.b. Given Name (First Name)
9.c. Middle Name
10. Relationship
Family Member 2
11.a. Family Name (Last Name)
11.b. Given Name (First Name)
11.c. Middle Name
12. Relationship
Parents' Names for the Subject of Record
Father 13.a. Family Name (Last Name)
13.b. Given Name (First Name)
13.c. Middle Name
Mother
14.a. Family Name (Last Name)
14.b. Given Name (First Name)
14.c. Middle Name
14.d. Maiden Name (if applicable)
15. Description of Records Sought. Provide a description of the records you are seeking. If you need additional space, use the space provided in Part 5. Additional Information.
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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
Mailing Address for the Subject of Record
2.a. In Care Of Name (if any)
2.b. Street Number and Name
2.c. Apt. Ste. Flr.
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.
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.
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
Date of Signature (mm/dd/yyyy)
Subscribed and sworn to before me on this
day of
in the year
Daytime Telephone Number
Signature of Notary
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 2]
Part 4. Verification of Identity and Subject of Record Consent
NOTE: 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
Part 4. Verification of Identity and Subject of Record Consent (continued)
[Page 3]
Mailing Address for the Subject of Record
2.a. In Care Of Name (if any)
2.b. Street Number and Name
2.c. Apt. Ste. Flr.
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.
NOTE: The Subject of Record MUST provide a signature in Item Number 8.a. Notarized Affidavit of Identity OR Item Number 8.b. Declaration Under Penalty of Perjury. If the Subject of Record is deceased, read Item Number 8.c. Deceased Subject of Record 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
Date of Signature (mm/dd/yyyy)
Subscribed and sworn to before me on this
day of
in the year
Daytime Telephone Number
Signature of Notary
My Commission Expires on (mm/dd/yyyy)
__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 4, Part 5. Additional Information
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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. Alien Registration Number (A-Number) (if any)
3.a. Page Number
3.b. Part Number
3.c. Item Number
3.d. ___________
4.a. Page Number
4.b. Part Number
4.c. Item Number
4.d. ___________
5.a. Page Number
5.b. Part Number
5.c. Item Number
5.d. ___________
6.a. Page Number
6.b. Part Number
6.c. Item Number
6.d. ___________
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[Page 4]
Part 5. Additional Information
[No Change] |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | TABLE OF CHANGE – FORM I-687 |
| Author | jdimpera |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |