Form 1-783 Applicant Information Form

1-783 (Rev. 6-8-2012) OMB-1110-0052

APPLICANT INFORMATION FORM

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 criminal 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

Last Four Digits of Social Security Number

Applicant Home Address

*Address
*City	*State
*Postal (Zip) Code	*Country

Phone Number

E-Mail

U.S. Citizen or Legal Permanent Resident Yes No
Country of Citizenship	Country of Residence

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)

CASHIER’S CHECK MONEY ORDER CREDIT CARD FORM

Number of Copies_______ X $18 per Copy = Total Payment of $___________Enclosed

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 for each person or copy requested - to the following address:

FBI CJIS Division – Record Request

1000 Custer Hollow Road

Clarksburg, West Virginia 26306

You may request a copy of your own identification record to review it or obtain a change, correction, or an update to the record.