Uscis Form G-639 - Freedom Of Information/privacy Act Request Page 3
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4Part 4. Verification of Identity and Subject of
Signature and Notarized Affidavit or Declaration
Record Consent (continued)
of the Subject of Record
Select only one box.
Mailing Address for the Subject of Record
NOTE: The Subject of Record MUST provide a signature in
2.a.
In Care Of Name (if any)
Item Number 8.a. Notarized Affidavit of Identity OR Item
Number 8.b. Sworn Declaration Under Penalty of Perjury. If
the Subject of Record is deceased, read Item Number 8.c. and
2.b.
Street Number
attach proof of death.
and Name
8.a.
Notarized Affidavit of Identity (Do NOT sign and
2.c.
Apt.
Ste.
Flr.
date below until the notary public provides
instructions to you.)
2.d.
City or Town
By my signature, I consent to USCIS releasing the
2.e.
State
2.f.
ZIP Code
requested records to the requestor (if applicable)
named in Part 2. I also consent to pay all costs
2.g.
Province
incurred for search, duplication, and review of
documents up to $25 (if filing this request for myself).
2.h. Postal Code
2.i.
Country
Signature of Subject of Record
Date of Signature (mm/dd/yyyy)
Other Information for the Subject of Record
3.
Date of Birth (mm/dd/yyyy)
Subscribed and sworn to before me on this
4.
Country of Birth
day of
in the year
.
Daytime Telephone Number
Contact Information for the Subject of Record
Signature of Notary
Providing this information is optional.
5.
Daytime Telephone Number
My Commission Expires on
8.b.
Declaration Under Penalty of Perjury
6.
Mobile Telephone Number (if any)
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
7.
Email Address (if any)
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
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