Form G-884 Request for the Return of Original Documents

Request for the Return
of Original Documents

USCIS
Form G-884

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

For
USCIS
Use
Only

OMB No. 1615-0100
Expires 06/30/2017

Remarks

File No
Date

DRAFT
NOT FOR
PRODUCTION
07/15/2016

► START HERE - Type or print in black ink.

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

IMPORTANT NOTE: You do not need to file this form if you submitted original documents because USCIS requested originals.
We will automatically return original documents that we requested once we no longer need them. Please refer to the instructions of
the form you filed to determine whether non-requested original documents are available for return or destroyed after electronic
processing.
1.

Your Full Name

Family Name (Last Name)

2.

3.

Given Name (First Name)

Middle Name

Mailing Address

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Alien Registration Number (A-Number) (if any) 4.

ZIP Code

City/Town/Village of Birth

► A5.

Country of Birth

8.

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

Form G-884 06/15/15

6.

Date of Birth (mm/dd/yyyy)

7.

Daytime Telephone Number

Page 1 of 3

Part 2. Data for Identification of Personal Record
1.

Subject's Full Name
Family Name (Last Name)

2.

Given Name (First Name)

Middle Name

Given Name (First Name)

Middle Name

Other Names Used (if any)
Family Name (Last Name)

DRAFT
NOT FOR
PRODUCTION
07/15/2016

3.

Date of Birth (mm/dd/yyyy)

4.

Place of Birth
City or Town

State or Province

Country

Entry Into the United States
5.

Date of Entry (mm/dd/yyyy)

6.

7.

Type of Entry (for example, visitor, student, etc.)

Port-of-Entry

8.

A-Number (if any)
► A-

U.S. Citizenship Information
9.

Name on Certificate of Naturalization
Family Name (Last Name)

Given Name (First Name)

10. Certificate of Naturalization Number

Middle Name

11. Certificate of Naturalization Date
(mm/dd/yyyy)

12. Name on Certificate of Citizenship
Family Name (Last Name)

Given Name (First Name)

Middle Name

14. Certificate of Citizenship Date

13. Certificate of Citizenship Number

(mm/dd/yyyy)
15. Naturalization Court/USCIS Office and Location

16. Verification of Requester's Identity
In Person With Identification

Form G-884 06/15/15

Legal Photocopies

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Part 3. Signature of Requester - Affidavit of Identity
NOTE: Read the Penalties section of the Form G-884 Instructions before completing this part.
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.
1.

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

2.

Print Your Full Name

DRAFT
NOT FOR
PRODUCTION
07/15/2016

Family Name (Last Name)

3.

Given Name (First Name)

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

Middle Name

4.

Date (mm/dd/yyyy)

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.
5.

Signature of USCIS Official

6.

Title

8.

Printed Name of USCIS Official
Family Name (Last Name)

7.

Given Name (First Name)

Date (mm/dd/yyyy)

Middle Name

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.
9.

Printed Name of Certifying Official
Family Name (Last Name)

Given Name (First Name)

Middle Name

10. Signature of Certifying Official

11. In and for the:

12. Date (mm/dd/yyyy)

Given under my hand and official seal

Form G-884 06/15/15

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