Family Member 2
Part 3. Description of Records Requested
(continued)
11.a.
Family Name
(Last Name)
Other Names Used by the Subject of Record (if any)
11.b.
Given Name
(First Name)
Provide all other names you have ever used, including aliases,
11.c.
Middle Name
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 5.
12.
Relationship
Additional Information.
3.a. Family Name
(Last Name)
Parents' Names for the Subject of Record
3.b.
Given Name
(First Name)
Father
3.c.
Middle Name
13.a. Family Name
(Last Name)
Full Name of the Subject of Record at Time of
13.b.
Given Name
Entry into the United States
(First Name)
13.c.
Middle Name
4.a.
Family Name
(Last Name)
4.b.
Given Name
Mother
(First Name)
14.a.
Family Name
4.c.
Middle Name
(Last Name)
14.b.
Given Name
(First Name)
Other Information About the Subject of Record
14.c.
Middle Name
5.
Form I-94 Number Arrival-Departure Record
►
14.d. Maiden Name (if applicable)
6.
Alien Registration Number (A-Number) (if any)
15.
Description of Records Sought.
►
A-
Provide a description of the records you are seeking. If
7.
USCIS Online Account Number (if any)
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
Part 4. Verification of Identity and Subject of
or children. If you need extra space to complete this section,
Record Consent
use the space provided in Part 5. Additional Information.
NOTE: Complete all applicable Item Numbers. In addition,
Family Member 1
the Subject of Record MUST sign Part 4. of this request.
9.a. Family Name
(Last Name)
Full Name of the Subject of Record
9.b.
Given Name
(First Name)
1.a. Family Name
(Last Name)
9.c.
Middle Name
1.b.
Given Name
(First Name)
10.
Relationship
1.c.
Middle Name
Form G-639 04/17/17 N
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