Form G-79A Information Related to Beneficiary of Private Bill

DEPARTMENT OF HOMELAND SECURITY
U.S. Immigration and Customs Enforcement

INFORMATION RELATING TO BENEFICIARY OF PRIVATE BILL
OMB NO. 1653-0026
Expires: 1/31/2016

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)

Sex

Place of birth
Complexion

Height
ft.

A-

Naturalization Certificate Number

Other names used (including maiden name)
Date of birth

Alien Registration Number

Citizenship (country)
Weight

in.

Eyes

Hair

Visible marks or scars

lbs.

2. RESIDENCE DATA
List complete addresses, including zip code if possible, for past 10 years. (If additional space is needed, use a blank continuation page.)
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. (If additional space is needed, use a blank continuation page.)
Full name and address of employer

Type of work

Present salary

$

United States Social Security Number
Per

Show any other present income.

ICE Form G-79A (1/13)

From
To
Month Year Month Year

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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. MARITAL DATA
Name of present spouse

Address of present spouse

Date of birth of spouse

Place of birth of spouse

Date of marriage

Place of marriage

Citizenship of spouse

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

Citizenship

Place of birth

Mother's name
Date of birth

Address if living (If deceased, write "Deceased")
Place of birth

10. SELECTIVE SERVICE DATA (If applicable)
Number and location of local board where registered

Citizenship

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
If discharged, show type of discharge received (Honorable,
dishonorable, etc.)

From
Present APO service address

Rank at time of discharge

ICE Form G-79A (1/13)

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OMB NO. 1653-0026
Expires: 01/31/2016
12. DATA RELATING TO UNITED STATES ENTRIES AND DEPARTURES
Status at time of entry
Date of entry
Port of entry
(Visitor, permanent resident, etc.)

Date of departure

13. DATA CONCERNING VISAS
a. If you were ever refused a visa by an American Consulate, fill in the following:
Location of Consul

Port of departure

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)
Date filed

Place filed

Yes

No

Was application approved
Date:
Yes
No

d. If you have ever registered with an American Consulate show the following:
Location of Consulate

Date registered

14. LIST PRESENT AND PAST MEMBERSHIP IN ALL ORGANIZATIONS, CLUBS, ASSOCIATIONS, ETC.
Dates of membership
Name of organization
Location
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:
Dates
Name and location of hospital or institution
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 the
beneficiary's behalf (include any outstanding acts benefiting the United States or other friendly nations which would be of interest to
Congress)

ICE Form G-79A (1/13)

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OMB. NO. 1653-0026
Expires 01/31/2016

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 BENEFICIARY'S BROTHERS AND SISTERS (List all living brothers and sisters - include half or step
brothers and sisters)
Name

Age

Address

20. DATA RELATING TO BENEFICIARY WHO HAS BEEN OR WILL BE ADOPTED
Name of child prior to adoption
Date of adoption
The adoption was

by proxy

with both adoptive parents present

Citizenship

Place of adoption (Include court)

with one adoptive parent present.

Date consented
The child's parents consented to the adoption
No
Yes
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

ICE Form G-79A (1/13)

Address

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Date

Privacy Statement
Authority and Purpose: The Immigration and Nationality Act, as amended, (8 U.S.C. 1357) authorizes the collection of
information from any alien or person believed to be an alien as to his right to be or to remain in the United States. In this
instance, the purpose of gathering information is to assist the Judiciary Committee and Congress in determining whether the
immigration related private bill is necessary and whether the subject of the bill is worthy of the relief proposed.
Disclosure: Furnishing this information is voluntary; however, failure to provide it may result in the non-issuance of the
desired immigration related benefit.
Routine Uses: The information provided will be disclosed to the Judiciary Committee of either House of Congress, which
requires the information in order to hold hearings on and consider the merits of the immigration related private bill. The
information provided may also be disclosed to other federal agencies in order to verify or ascertain information concerning
the beneficiary of the private bill.
Public Reporting Burden. The U.S. Immigration and Customs Enforcement is collecting this information as a part of its
agency mission under the Department of Homeland Security. The estimated average time to review the instructions, search
existing data sources, gather and maintain the data needed and completing and reviewing this collection of information is 60
minutes (1.0 hours) per response. An agency may not conduct or sponsor, and a person is not required to respond to, an
information collection unless it displays a currently valid OMB Control Number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the
Department of Homeland Security, U.S. Immigration and Customs Enforcement, 500 12th Street, S.W., Room 3138,
Washington, D.C. 20536 (Do not mail your completed application to this address.)

ICE Form G-79A (1/13)

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Continuation Page

ICE Form G-79A (1/13)

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