Form G-79A Data Relating to Beneficiary of Private Bill

DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement

OMB. NO. 1653-0026

RELATING TO BENEFICIARY OF PRIVATE BILL Expires 03/31/2008

File Number

TO ASSIST U.S. IMMIGRATION AND CUSTOMS ENFORCEMENT IN MAKING ITS REPORT TO CONGRESS WITH RESPECT TO PRIVATE BILL NO. _________________ FOR RELIEF OF __________________________________________________________

IN WHICH I AM THE BENEFICIARY INTERESTED PARTY, THE FOLLOWING INFORMATION IS FURNISHED.

Submit separate form for each beneficiary or interested party. If you need more space to answer fully any questions on this form, use a separate sheet, identify each answer with the number of the corresponding question, and date and sign each sheet.

PLEASE TYPE OR PRINT.

1. PERSONAL DATA

Name (Last in caps) (First) (Middle)							Alien Registration Number A -
Other names used (including maiden name)							Naturalization Certificate Number
Date of birth		Place of birth					Citizenship (country)
Sex	Complexion	Height ft. in.	Weight lbs.	Eyes	Hair	Visible marks or scars

2. Residence Data

List complete addresses, including zip code if possible, for past 10 years.
Street and Number	City	Province	Country	From		To
				Month	Year	Month	Year

3. EDUCATIONAL DATA

Show name and location of last school attended including highest grade completed or degrees earned and date.

4. EMPLOYMENT DATA

Employment during past 5 years.
Full name and address of employer	Type of work	From		To
		Month	Year	Month	Year
Present salary $ ____________________________ Per ______________________	United States Social Security Number
Show any other present income.

ICE Form G-79A (07/05)

5. ASSETS AND LIABILITIES

List value of each asset and your equity in each, and show all debts. The value of all personal property may be shown as a single figure.

6. MARITIAL DATA

Name of present spouse		Address of present spouse
Date of birth of spouse	Place of birth of spouse		Citizenship of spouse
Date of marriage	Place of marriage		Present spouse depends on me for support Yes No
Show the following for all previous marriages (Name of spouse, date and place of marriage, date and place marriage terminated and how marriage was terminated)

7. DATA CONCERNING CHILDREN (If child depends on you for support, place an “X” before his or her name)

Name of child (Include address if not living with you)	Date of birth	Place of birth	Citizenship

8. OTHER PERSONS DEPENDENT UPON ME FOR SUPPORT (Do not include children named in item 7 or present spouse)

Name	Relationship	Amount (Weekly or monthly)

9. DATA RELATING TO PARENTS

Father’s name		Address if living (If deceased, write “Deceased”)
Date of birth	Place of birth	Citizenship
Mother’s name		Address if living (If deceased, write “Deceased”)
Date of birth	Place of birth	Citizenship

10. SELECTIVE SERVICE DATA (If applicable)

Number and location of local board where registered

Date registered

Classification

11. MILITARY SERVICE DATA (If you are now serving or have ever served in the U.S. Armed Forces)

Branch of service	Serial number	Dates served From ________________________ To _____________________________
If discharged, show type of discharge received (Honorable, dishonorable, etc.)
		Present APO service address
Rank at time of discharge

ICE Form G-79A (07/05)

12. DATA RELATING TO UNITED STATES ENTRIES AND DEPARTURES

Date of entry	Port of entry	Status at time of entry (Visitor, permanent resident, etc.)	Date of departure	Port of departure

13 DATA CONCERNING VISAS

a. If you were ever refused a visa by an American Consul fill in the following:
Location of Consul				Date visa refused
Reason for refusal
b. If you are the beneficiary of a Preference Immigrant Visa Petition fill in the following: (Check one) A 1st 2nd 3rd 4th 5th 6th Preference Immigrant Visa Petition in my behalf was filed on: _____________________
Date filed	Place filed	Person who filed petition
c. Did you ever apply for Classification as a Conditional Entrant (7th Preference) Yes No
Date filed	Place filed	Was application approved Yes No Date:
d. If you have ever registered with an American Consul show the following:
Location of Consulate			Date registered

14. LIST PRESENT AND PAST MEMBERSHIP IN ALL ORGANIZATIONS, CLUBS, ASSOCIATIONS, ETC.

Name of organization	Location	Dates of membership
		From	To

15. IF YOU HAVE EVER BEEN ARRESTED ANYWHERE SHOW THE FOLLOWING: (Include traffic violations)

Place arrested

Date arrested

Charge

Disposition

16. IF YOU HAVE EVER BEEN HOSPITALIZED OR INSTITUTIONALIZED SHOW THE FOLLOWING:

Name and location of hospital or institution	Dates		Reason
	From	To

17. DATA CONCERNING NECESSITY FOR PRIVATE BILL

Show in this block any additional information concerning the beneficiary and/or concerning the necessity for a private bill in his or her behalf (include any outstanding acts benefiting the United States or other friendly nations which would be of interest to Congress)

ICE Form G-79A (07/05)

18. OTHER DATA CONCERNING THIS CASE

Please include in this block any derogatory information concerning this case which you believe would aid the Congress in its consideration of this bill. Also, if you wish this information to be treated in a confidential manner, please so state and give reason for desiring such treatment.

19. DATA RELATING TO BENEFICIARIES BROTHERS AND SISTERS ( List all living brothers and sisters - include half or step brothers and sisters)

Name	Age	Address	Citizenship

20. data relating to beneficiary who has been or will be adopted

Name of child prior to adoption	Date of adoption	Place of adoption (Include court)
The adoption was by proxy with both adoptive parents present with one adoptive parent present. The child’s parents consented to the adoption No Yes Date consented _______________________________________
Name and addresses of child’s living natural parents and step parents

Child lives with (include address)

Child has resided with adoptive parents Dates: From To

21. DATA CONCERNING ANY PERSON IN THE UNITED STATES WHO COULD FURNISH ADDITIONAL INFORMATION

(State whether relative, or business or social acquaintance)

Name ____________________________________________________________________ Relationship ____________________________________________

Address __________________________________________________________________________________________________________________________

(Street and number) (City) (State) (Zip Code)

22. signature of beneficiary or interested party

I hereby certify that the information given on this form is complete and true to the best of my knowledge and belief.

______________________________ ___________________________________________________________________________________________

Date Signature

23. signature of person prEparing form, if other than beneficiary or interested party

I declare that this document was prepared by me at the request of the beneficiary or interested party and is based on all information of which I have any knowledge.

______________________________________________ _______________________________________________________ _______________________

Signature Address Date

Public Reporting Burden. Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. We try to create forms and instructions that are accurate, can be easily understood, and which impose the least possible burden on you to provide us with information. Often this is difficult because some immigration laws are very complex. The estimated average time to complete and file this application is 1 hour per application. If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the Immigration and Customs Enforcement, OAM, 425 I Street, N.W., Room 1122, Washington DC 20536. (Do not mail your form to this address).

ICE Form G-79A (07/05)