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 03/31/2017

DRAFT
Not For
Production
02/28/2017

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

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.
1.a.

Freedom of Information Act (FOIA)/Privacy Act (PA)

1.b.

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 Certification

No

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

Requestor's Full Name

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

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

Part 3. Description of Records Requested

2.c. Middle Name

Requestor's Mailing Address
3.a. In Care Of Name (if any)

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.b. Street Number
and Name
3.c.

Apt.

Ste.

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.

ZIP Code

3.g. Province

Full Name of the Subject of Record
3.h. Postal Code
3.i.

Country

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

Form G-639 03/31/15 N

Page 1 of 4

Part 3. Description of Records Requested
(continued)
Other Names Used by the Subject of Record (if any)

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

6.

7.

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

Form I-94 Number Arrival-Departure Record
►

14.d. Maiden Name (if applicable)

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

15.

USCIS Online Account Number (if any)
►

8.

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

DRAFT
Not For
Production
02/28/2017

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.

5.

Family Member 2

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.

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.

Part 4. Verification of Identity and Subject of
Record Consent

Family Member 1

NOTE: Complete all applicable Item Numbers. In addition,
the Subject of Record MUST sign Part 4. of this request.

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

Full Name of the Subject of Record

9.c. Middle Name
10.

Relationship

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name

Form G-639 03/31/15 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.

DRAFT
Not For
Production
02/28/2017

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.

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

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

Apt.

Ste.

Flr.

8.a.

(Do NOT sign and date below until the notary public
provides instructions to you.)

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

2.f.

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

2.h. Postal Code
2.i.

Country

Notarized Affidavit of Identity

Signature of Subject of Record

Other Information for the Subject of Record
3.

Date of Birth (mm/dd/yyyy)

4.

Country of Birth

Date of Signature (mm/dd/yyyy)

Subscribed and sworn to before me on this
day of

.

in the year

Daytime Telephone Number

Contact Information for the Subject of Record
Providing this information is optional.
5.

Signature of Notary

Daytime Telephone Number
My Commission Expires on (mm/dd/yyyy)

6.

7.

Mobile Telephone Number (if any)

Email Address (if any)

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.)
Form G-639 03/31/15 N

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.

5.b. Part Number

5.c. Item Number

5.d.

DRAFT
Not For
Production
02/28/2017

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

1.c. Middle Name
2.

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

3.a. Page Number

3.d.

3.b. Part Number

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.

Form G-639 03/31/15 N

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