Form I-783 - Privacy Act Statement Template
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1I-783 (Rev. 04-02-2014)
OMB-1110-0052
PRIVACY ACT STATEMENT
The FBI’s acquisition, retention, and sharing of information submitted on this form is generally authorized under 28 USC 534 and 28 CFR 16.30-16.34. The purpose for requesting this information from you is to provide the
FBI with a minimum of identifying data to permit an accurate and timely search of identity history identification records. Providing this information (including your Social Security Account Number) is voluntary; however,
failure to provide the information may affect the completion of your request. The information reported on this form may be disclosed pursuant to your consent, and may also be disclosed by the FBI without your consent pursuant
to the Privacy Act of 1974 and all applicable routine uses. Under the Paperwork Reduction Act, you are not required to complete this form unless it contains a valid OMB control number. The form takes approximately 3 minutes
to complete.
Applicant Information * Denotes Required Fields
*Last Name
*First Name
Middle Name 1
Middle Name 2
*Date of Birth:
*Place of Birth:
U.S. Citizen or Legal Permanent Resident:
Yes
No
*Country of Citizenship:
Country of Residence:
Prisoner Number (if applicable):
*Last Four Digits of Social Security Number:
*Height:
*Weight:
*Hair
(please check appropriate box):
Bald
Black
Blonde/Strawberry
Blue
Brown
Gray
Green
Orange
Pink
Purple
Red/Auburn
Sandy
Unknown
White
*Eyes (please check appropriate box):
Black
Blue
Brown
Gray
Green
Hazel
Maroon
Multicolored
Pink
Unknown
Applicant Home Address
*Address
*City
*State
*Postal (Zip) Code
*Country
Phone Number
E-Mail
Mail Results to Address
C/O
ATTN
Address
City
State
Postal (Zip) Code
Country
Phone Number (if different from above)
Payment Enclosed: (please check appropriate box)
CERTIFIED CHECK
MONEY ORDER
CREDIT CARD FORM
Reason for Request:
Personal review
Challenge information on your record
Adoption of a child in the U.S.
International adoption
Live, work, or travel in a foreign country
Other
* APPLICANT SIGNATURE
DATE
Mail
the signed applicant information form, fingerprint card, and payment of $18 U.S. dollars to the following address:
FBI CJIS Division – Summary Request
1000 Custer Hollow Road
Clarksburg, West Virginia 26306
You may request a copy of your own Identity History Summary to review it
or obtain a change, correction, or an update to the summary.
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