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 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
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)/Privacy Act (PA)
1.b.
Amendment of Record (PA only)
6.
Requestor's Email Address (if any)
Part 2. Requestor Information
Requestor's Certification
1.
Are you the Subject of Record for this request?
Yes
No
By my signature, I consent to pay all costs incurred for search,
duplication, and review of documents up to $25. (See Form
If you answered "No" to Item Number 1., provide the
G-639 Instructions for more information.)
information requested in Part 2. If you answered "Yes" to
Requestor's Signature
Item Number 1., skip to Part 3.
7.a.
Requestor's Full Name
7.b.
Date of Signature
(mm/dd/yyyy)
2.a. Family Name
(Last Name)
2.b.
Given Name
Part 3. Description of Records Requested
(First Name)
NOTE: While you are not required to respond to every item in
2.c.
Middle Name
Part 3., failure to provide complete and specific information
may delay processing of your request or create an inability for
Requestor's Mailing Address
U.S. Citizenship and Immigration Services (USCIS) to locate
the records or information requested.
3.a.
In Care Of Name (if any)
1.
Purpose (Optional: You are not required to state the
purpose of your request. However, providing this
3.b.
Street Number
information may assist USCIS in locating the records
and Name
needed to respond to your request.)
3.c.
Apt.
Ste.
Flr.
3.d.
City or Town
3.e.
State
3.f.
ZIP Code
3.g.
Province
Full Name of the Subject of Record
3.h. Postal Code
2.a. Family Name
(Last Name)
3.i.
Country
2.b.
Given Name
(First Name)
2.c.
Middle Name
Form G-639 04/17/17 N
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