OMB NO. 1652-0044 Traveler Inquiry Form

Traveler Inquiry Form
I. Your Travel Experience
Thank you for contacting the Department of Homeland Security Traveler Redress Inquiry Program (TRIP).
Please check ALL scenarios that describe your travel experience:
I am always subjected to additional screening when going through an airport security checkpoint
I was denied boarding
I am unable to print a boarding pass at the airport kiosk or at home
I am directed to ticket counter every time I fly
The airline ticket agent states that I am on a Federal Government Watch List
I was detained during my travel experience
A ticket agent took my identification and “called someone” before handing me a boarding pass
I missed my flight while attempting to obtain a boarding pass
I am repeatedly referred for secondary screening when clearing U.S. Customs and Border Protection
I was denied entry into the United States
I am a foreign student or exchange visitor who is unable to travel due to my status
I was told by U.S. Customs and Border Protection at a U.S. port of entry that my fingerprints need to be corrected
by US-VISIT
I feel I have been discriminated against by a government agent based on race, disability, religion, gender, or
ethnicity
I feel my personal information has been misused
I was given an IBIS Fact Sheet by a U.S. Customs and Border Protection officer
Other travel related issue
II. Personal Information
Full Name:
Date of Birth:

Sex:

Male
Female

First

Middle

Last

Place of Birth:

mm/dd/yyyy

Height:

Weight:

City or Town/State or Province/Country

Hair Color:

Eye Color:

III. Contact Information
Mailing Address:
Street or PO Box
City or Town

Apt. No.
State or Province

Zip or Postal Code

Country

Physical Address (if different):
Street
City or Town

Home Telephone:
E-mail Address:

Apt. No.
State or Province

Work Telephone:

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Zip or Postal Code

Country

Traveler Inquiry Form
IV. Additional Information (if applicable)
Date of Entry into U.S.:(mm/dd/yyyy)
Port of Entry into U.S.:
Departure Date from U.S.:
U.S. Port of Departure:

Name of Airline or Ship:
Flight or Cruise Number:
Other Names Used:
Name at Entry into U.S.:

V. Required Documentation and Information
U.S. citizens: Please provide a legible, unexpired copy of a U.S. passport. If you do not have a U.S. passport, please
provide at least one legible, unexpired copy of a government-issued identification document from the list below,
preferably a photo ID. For minors (individuals under the age of 18), a copy of a certified birth certificate is the only
identity document required.
Non-U.S. citizens: Please provide legible, unexpired copies of the biographical pages of your passport/travel document,
and/or copies of any U.S. government-issued travel documents.
Check the box next to the document(s) you are submitting with this form:
Documentation
Passport
Driver’s License
Birth Certificate
Voter Registration Card
Military Identification Card
Certificate of Release or Discharge
from Active Duty (DD Form 214)
Government Identification Card
Certificate of Citizenship

Naturalization Certificate
Immigrant/Non-immigrant Visa
Alien Registration
Petition or Claim Receipt
I-94 Admission
FAST
SENTRI

Registration No.:
Country of Issuance:
License No.
State of Issuance:
Registration No.
Place of Issuance:
Number:
Place of Issuance:
Number:
Air Force
Check one:
Discharge Date: (mm/dd/yyyy)
Air Force
Check one:
Number:
Federal
Check one:
Number:
Place of Issuance:
Number:
State of Issuance
Date: (mm/dd/yyyy)
Number:
Number:
Date: (mm/dd/yyyy)
Number:
Date: (mm/dd/yyyy)
Number:
Date: (mm/dd/yyyy)
Number:
Date: (mm/dd/yyyy)
Number:
Date: (mm/dd/yyyy)
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Information

Army

Marines

Navy

Coast Guard

Army

Marines

Navy

Coast Guard

State

Local

Traveler Inquiry Form
Number:
Date: (mm/dd/yyyy)
Number:
Date: (mm/dd/yyyy)
Number:
Date: (mm/dd/yyyy)

NEXUS
Border Crossing Card
SEVIS

VI. Incident Details
Please briefly describe your travel experience:

VII. Acknowledgement
The information I have provided on this application is true, complete, and correct to the best of my knowledge and is provided in good
faith. I understand that knowingly and willfully making any materially false statement, or omission of a material fact, on this
application can be punished by fine or imprisonment or both (see section 1001 of Title 18 United States Code).
I understand the above information and am voluntarily submitting this information to the Department of Homeland Security.

Date:

Full Name:

Signature:

PAPERWORK REDUCTION ACT STATEMENT: Through this information collection, DHS is gathering
information about you to conduct redress procedures, as an individual who believes he or she has been (1) denied or
delayed boarding,(2) denied or delayed entry into or departure from the United States as a port of entry, or (3) identified
for additional screening at our Nation's transportation hubs, including airports, seaports, train stations and land borders.
The public burden for this collection of information is estimated to be five minutes. This is a voluntary collection of
information. If you have any comments on this form, you may contact the Transportation Security Administration, Office
of Transportation Security Redress, TSA-901, 601 S. 12th St., Arlington, VA 22202. An agency may not conduct or
sponsor, and persons are not required to respond to, a collection of information unless it displays a currently valid OMB
control number. The OMB control number assigned to this collection is 1652-0044, which expires 05/31/2007.

PRIVACY ACT NOTICE AUTHORITY: Title IV of the Intelligence Reform and Terrorism Prevention Act of 2004
authorizes DHS to take security measures to protect travel, and under Subtitle B, Section 4012(1)(G), the Act directs DHS
to provide appeal and correction opportunities for travelers whose information may be incorrect. Principal Purposes: DHS
will use this information in order to assist you with seeking redress in connection with travel. Routine Uses: DHS will use
and disclose this information to appropriate governmental agencies to verify your identity, distinguish your identity from
that of another individual, such as someone included on a watch list, and/or address your redress request. Additionally,
limited information may be shared with non-governmental entities, such as air carriers, where necessary for the sole
purpose of carrying out your redress request. Disclosure: Furnishing this information is voluntary; however, the
Department of Homeland Security may not be able to process your redress inquiry without the information requested.

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Traveler Inquiry Form
Please mail or e-mail your completed Traveler Inquiry Form and copies of identity documents to
the Department of Homeland Security.
Mailing Instructions
Please mail the completed form and copies of identity documents to:
DHS Traveler Redress Inquiry Program (TRIP)
601 South 12th Street, TSA-901
Arlington, VA 22202-4220

E-mailing Instructions
Please e-mail the completed form and copies of identity documents to:
[email protected]

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