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 04/30/2020 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. 1.b. Freedom of Information Act (FOIA)/Privacy Act (PA) Amendment of Record (PA only) 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) 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. No 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 Requestor's Full Name 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 7.b. Date of Signature (mm/dd/yyyy) 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.) 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.g. Province 3.f. ZIP Code 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 04/17/17 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 4 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 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 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 14.d. Maiden Name (if applicable) 6. Alien Registration Number (A-Number) (if any) A7. USCIS Online Account Number (if any) 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. 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 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 Form G-639 04/17/17 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 Part 4. Verification of Identity and Subject of Record Consent (continued) Mailing Address for the Subject of Record 2.a. In Care Of Name (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. 2.b. Street Number and Name 2.c. Apt. Ste. Flr. 8.a. Notarized Affidavit of Identity (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.h. Postal Code 2.i. Country 2.f. ZIP Code 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 Other Information for the Subject of Record 3. 4. Date of Birth (mm/dd/yyyy) Country of Birth Date of Signature (mm/dd/yyyy) Subscribed and sworn to before me on this day of Daytime Telephone Number in the year . Contact Information for the Subject of Record Providing this information is optional. 5. Daytime Telephone Number My Commission Expires on (mm/dd/yyyy) 6. Mobile Telephone Number (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 Notary 7. Email Address (if any) 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 04/17/17 N A