Request for the Return of Original Documents Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form G-884 OMB No. 1615-0100 Expires 09/30/2018 For USCIS Use Only File No Date Remarks START HERE - Type or print in black ink. Part 1. Information About You (Person requesting the return of original documents) IMPORTANT NOTE: You do not need to file this form if you submitted original documents because USCIS requested originals. We will automatically return original documents that we requested once we no longer need them. Please refer to the instructions of the form you filed to determine whether non-requested original documents are available for return or destroyed after electronic processing. 1. Your Full Name Family Name (Last Name) Given Name (First Name) Middle Name 2. Mailing Address Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code 3. Alien Registration Number (A-Number) (if any) 4. City/Town/Village of Birth A6. Date of Birth (mm/dd/yyyy) 7. Daytime Telephone Number 5. Country of Birth 8. Specific information about desired document(s) or record(s) (For example, marriage license, birth certificate, death certificate, etc.) Form G-884 09/19/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 Part 2. Data for Identification of Personal Record 1. Subject's Full Name Family Name (Last Name) Given Name (First Name) Middle Name 2. Other Names Used (if any) Family Name (Last Name) Given Name (First Name) Middle Name 3. Date of Birth (mm/dd/yyyy) 4. Place of Birth City or Town State or Province Country Entry Into the United States 5. Date of Entry (mm/dd/yyyy) 6. Port-of-Entry 7. Type of Entry (for example, visitor, student, etc.) 8. A-Number (if any) A- U.S. Citizenship Information 9. Name on Certificate of Naturalization Family Name (Last Name) Given Name (First Name) Middle Name 10. Certificate of Naturalization Number 11. Certificate of Naturalization Date (mm/dd/yyyy) 12. Name on Certificate of Citizenship Family Name (Last Name) Given Name (First Name) Middle Name 13. Certificate of Citizenship Number 14. Certificate of Citizenship Date (mm/dd/yyyy) 15. Naturalization Court/USCIS Office and Location 16. Verification of Requester's Identity In Person With Identification Legal Photocopies Form G-884 09/19/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 Part 3. Signature of Requester - Affidavit of Identity NOTE: Read the Penalties section of the Form G-884 Instructions before completing this part. I certify, under penalty of perjury under the laws of the United States of America, that this request and evidence submitted is all true and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration Services needs to respond to my request. 1. 2. swear Affirm that I am the person named in Part 1. on Page 1 of this form. I understand that if I willfully make false I statements on this form, I may be punished by fine or imprisonment (18 U.S.C. 1101). Print Your Full Name Family Name (Last Name) Given Name (First Name) Middle Name 3. Signature (Your signature must be notarized. Do not sign until you are before the Certifying Official) 4. Date (mm/dd/yyyy) I do hereby certify that the requester named in Part 1. on Page 1 of this form personally appeared before me and executed the Affidavit of Identity. 5. Signature of USCIS Official 6. Title 7. Date (mm/dd/yyyy) 8. Printed Name of USCIS Official Family Name (Last Name) Given Name (First Name) Middle Name Certifying Official I do hereby certify that the requester named in Part 1. on Page 1 of this form personally appeared before me and executed the Affidavit of Identity. 9. Printed Name of Certifying Official Family Name (Last Name) Given Name (First Name) Middle Name 10. Signature of Certifying Official 11. In and for the: 12. Date (mm/dd/yyyy) Given under my hand and official seal Form G-884 09/19/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3