Form 1-783 Identity Summary History Request Form

1-783 (Rev. 07-31-2023)

OMB-1110-0052

IDENTITY HISTORY SUMMARY REQUEST FORM
* Denotes Required Fields

*Last Name
Middle Name 1

*First Name
Middle Name 2

*Date of Birth

*Place of Birth

*Country of Citizenship

Country of Residence

*U.S. Citizen or Legal Permanent Resident
Yes
No (please check appropriate box)
Prisoner Number (if applicable)

*Last Four Digits of Social Security Number
*Race (please check appropriate box)
Asian

Black

Caucasian

Native American

Unknown

*Sex (please check appropriate box)
Male

Female

Non-binary

c/o (care of)
*Address

Attention

*City
*Postal (Zip) Code
Phone Number

*State
*Country
E-Mail

Payment Enclosed: (please check appropriate box)
Certified Check

Money Order

Credit Card Form

You may request a copy of your own Identity History Summary to review it or obtain a change, correction, or an update to the
summary. This is not a national background check and may not include information from state repositories which would be included
on an employment background check. If you are requesting a background check for employment or licensing within the U.S., you may
be required by state statute or federal law to submit your request through your state identification bureau, the requesting federal
agency, or another authorized channeling agency.

* Signature

Date____________________

Signature of person whose identity history is being requested

Mail the signed requestor information form, fingerprint card, and payment of $18 U.S. dollars to the following address:

FBI CJIS Division – Summary Request
1000 Custer Hollow Road
Clarksburg, West Virginia 26306
PRIVACY ACT STATEMENT

The FBI’s acquisition, retention, and sharing of information submitted on this form is generally authorized under 28 USC 534 and 28 CFR 16.30-16.34. The purpose for requesting this information
from you is to provide the FBI with a minimum of identifying data to permit an accurate and timely search of FBI identification records. Providing this information (including your Social Security
Account Number) is voluntary; however, failure to provide the information may affect the completion of your request. The information reported on this form may be disclosed pursuant to your
consent and may also be disclosed by the FBI without your consent pursuant to the Privacy Act of 1974 and all applicable routine uses.

PAPERWORK REDUCTION ACT STATEMENT:

Under the Paperwork Reduction Act, you are not required to complete this form unless it contains a valid OMB control number. The form takes approximately 3 minutes to complete.