Part 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. Declaration Under Penalty of Perjury. If the
Subject of Record is deceased, read Item Number 8.c.
2.b.
Street Number
Deceased Subject of Record and attach proof of death.
and Name
8.a.
Notarized Affidavit of Identity
2.c.
Apt.
Ste.
Flr.
(Do NOT sign and date below until the notary public
2.d.
City or Town
provides instructions to you.)
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
Other Information for the Subject of Record
Date of Signature (mm/dd/yyyy)
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
Providing this information is optional.
Signature of Notary
5.
Daytime Telephone Number
My Commission Expires on (mm/dd/yyyy)
6.
Mobile Telephone Number (if any)
8.b.
Declaration Under Penalty of Perjury
By my signature, I consent to USCIS releasing the
requested records to the requestor (if applicable)
7.
Email Address (if any)
named in Part 2. I also consent to pay all costs
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 04/17/17 N
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