Freedom of Information/Privacy Act Request
USCIS
Form G-639
Department of Homeland Security
OMB No. 1615-0102
U.S. Citizenship and Immigration Services
Expires 03/31/2017
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
Requestor's Contact Information
Select only one box.
4.
Requestor's Daytime Telephone Number
NOTE: If you are filing this request on behalf of another
individual, respond as it would apply to that individual.
5.
Requestor's Mobile Telephone Number (if any)
1.a.
Freedom of Information Act (FOIA)
1.b.
Privacy Act (PA)
6.
Requestor's Email Address (if any)
1.c.
Amendment of Record (PA only)
Part 2. Requestor Information
Requestor's Certification
1.
Are you the Subject of Record for this request?
By my signature, I consent to pay all costs incurred for search,
duplication, and review of documents up to $25. (See Form
Yes
No
G-639 Instructions for more information.)
If you answered "No" to Item Number 1., provide the
Requestor's Signature
7.a.
information requested in Part 2. If you answered "Yes" to
Item Number 1., skip to Part 3.
7.b.
Date of Signature
(mm/dd/yyyy)
Requestor's Full Name
2.a. Family Name
Part 3. Description of Records Requested
(Last Name)
2.b.
Given Name
NOTE: While you are not required to respond to every item in
(First Name)
Part 3., failure to provide complete and specific information
2.c.
Middle Name
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.
Requestor's Mailing Address
1.
Purpose (Optional: You are not required to state the
3.a.
In Care Of Name (if any)
purpose of your request. However, providing this
information may assist USCIS in locating the records
needed to respond to your request.)
3.b.
Street Number
and Name
3.c.
Apt.
Ste.
Flr.
3.d.
City or Town
3.e.
State
3.f.
ZIP Code
Full Name of the Subject of Record
3.g.
Province
2.a. Family Name
3.h. Postal Code
(Last Name)
2.b.
Given Name
3.i.
Country
(First Name)
2.c.
Middle Name
Form G-639 03/31/15 N
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