Form G-884 Request for Return of Original Documents

OMB No. 1615-0100; Expires 02/28/2015

G-884, Request for the
Return of Original Documents

Department of Homeland Security
U.S. Citizenship and Immigration Services

START HERE - Type or print in black ink

For USCIS Use Only

Part 1. Information About You (Person requesting the return of original

Remarks

documents)
Given Name

Family Name

Middle Name

Apt./SuiteNumber

Mailing Address - Street Number and Name

File No.
Date

City

State

Zip Code

City/Town/Village of Birth

A-Number (if any)

Date of Birth
(mm/dd/yyyy)

Country of Birth

Daytime Phone Number
(with area code)

Specific information about desired document(s) or record(s) (e.g., marriage license, birth certificate, death certificate, etc.)

Part 2. Data for Identification of Personal Record
Family Name

Date of Birth
(mm/dd/yyyy)

Middle Name

Given Name

Place of Birth

Date of Entry
(mm/dd/yyyy)

Port of Entry

Other Names Used (if any)

Type of Entry
(visitor, student, etc.)

A-Number (if any)

Name on Certificate of Naturalization

Certificate of
Naturalization Number

Certificate of Naturalization
Date (mm/dd/yyyy)

Name on Certificate of Citizenship

Certificate of
Citizenship Number

Certificate of Citizenship
Date (mm/dd/yyyy)

Naturalization Court/USCIS Office and Location

Verification of Identity
In person with
identification

Legible photocopies
Form G-884 (02/27/13)Y

Part 3. Signature of Requester - Affidavit of Identity
I certify, under penalty of perjury under the laws of the United States of America, that this request and evidence submitted is all true
and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration Services needs to
respond to my request.
I

Swear

Affirm that I am the person named in Part 1 on Page 1 of this form. I understand that if I willfully make false

statements on this form, I may be punished by fine or imprisonment (18 U.S.C.1101).
Print Your Full Name

Date (mm/dd/yyyy)

Signature (Your signature must be notarized. Do not sign until before the Certifying Official)

I do hereby certify that the requester named in Part 1 on Page 1 of this form personally appeared before me and executed the
Affidavit of Identity.
Signature of USCIS Official

Date (mm/dd/yyyy)

Title

Printed Name of USCIS Official

Certifying Official
I do hereby certify that the requester named in Part 1 on Page 1 of this form personally appeared before me and executed the
Affidavit of Identity.
Printed Name of Certifying Official

Signature of Certifying Official

In and for the:

Given under my hand and official seal
Date (mm/dd/yyyy)

Form G-884 (02/27/13)Y Page 2