Form Table of Changes

TABLE OF CHANGES – FORM

Form G-639, Freedom of Information/Privacy Act Request

OMB Number: 1615-0102

06/18/2019

Reason for Revision:

Legend for Proposed Text:

• Black font = Current text

• Red font = Changes

Current Page Number and Section	Current Text	Proposed Text
Page 1,	[Page 1] NOTE: Use of this form is optional. USCIS accepts any written request, regardless of format, provided that the request complies with the applicable requirements under the FOIA and the Privacy Act. START HERE - Type or print in black ink.	[Page 1] NOTE: Use of this form is optional. USCIS accepts any written request, regardless of format, provided that the request complies with the applicable requirements under the FOIA and the Privacy Act. However, using this form can help ensure we have the appropriate information to handle your request. START HERE - Type or print in black ink.
Page 1, P art 1. Type of Request	[Page 1] Part 1. Type of Request Select only one box. NOTE: If you are filing this request on behalf of another individual, respond as it would apply to that individual. 1.a. Freedom of Information Act (FOIA)/Privacy Act (PA) 1.b. Amendment of Record (PA only)	[Page 1] [No change]
Page 1, Part 2. Requestor Information	[Page 1] Part 2. Requestor Information 1. Are you the Subject of Record for this request? Yes No If you answered "No" to Item Number 1., provide the information requested in Part 2. If you answered "Yes" to Item Number 1., skip to Part 3. [new] Requestor's Full Name 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name Requestor's Mailing Address 3.a. In Care Of Name (if any) 3.b. Street Number and Name 3.c. Apt./Ste./Flr. [Number] 3.d. City or Town 3.e. State 3.f. ZIP Code 3.g. Province 3.h. Postal Code 3.i. Country Requestor's Contact Information 4. Requestor's Daytime Telephone Number 5. Requestor's Mobile Telephone Number (if any) 6. Requestor's Email Address (if any) Requestor's Certification By my signature, I consent to pay all costs incurred for search, duplication, and review of documents up to $25. (See Form G-639 Instructions for more information.) 7.a. Requestor's Signature 7.b. Date of Signature (mm/dd/yyyy)	[Page 1] Part 2. Requestor Information 1. Are you the Subject of Record for this request? Yes No If you answered "Yes" to Item Number 1., skip to Part 3. If you answered "No" to Item Number 1., provide the information requested in Part 2., Item Numbers 2.a. – 3.c. Representative Role to the Subject of Record Select your representative role to the Subject of the Record 2.a. An Attorney 2.b. An Accredited Representative of a Qualified Organization 2.c. A Family Member Select the appropriate box to provide further information regarding your representative role to the Subject of the Record. 3.a. I am requesting information on behalf of my child or a minor I have guardianship over. 3.b. I am requesting information on behalf of someone who is deceased. 3.c. I am requesting information on behalf of someone for whom I have power of attorney. Requestor's Full Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Requestor's Mailing Address 5.a. In Care Of Name (if any) 5.b. Street Number and Name 5.c. Apt./Ste./Flr. [Number] 5.d. City or Town 5.e. State 5.f. ZIP Code 5.g. Province 5.h. Postal Code 5.i. Country Requestor's Contact Information 6. Requestor's Daytime Telephone Number 7. Requestor's Mobile Telephone Number (if any) 8. Requestor's Email Address (if any) Requestor's Certification By my signature, I consent to pay all costs incurred for search, duplication, and review of documents up to $25. (See the What Is the Filing Fee section in the Form G-639 Instructions for more information.) 9.a. Requestor's Signature 9.b. Date of Signature (mm/dd/yyyy)
Page 2-3, Part 3. Description of Records Requested	[Page 1] Part 3. Description of Records Requested NOTE: While you are not required to respond to every item in Part 3., failure to provide complete and specific information may delay processing of your request or create an inability for U.S. Citizenship and Immigration Services (USCIS) to locate the records or information requested. 1. Purpose (Optional: You are not required to state the purpose of your request. However, providing this information may assist USCIS in locating the records needed to respond to your request.) [Fillable field] Full Name of the Subject of Record 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name [Page 2] Other Names Used by the Subject of Record (if any) Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 5. Additional Information. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name Full Name of the Subject of Record at Time of Entry into the United States 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Other Information About the Subject of Record 5. Form I-94 Number Arrival-Departure Record 6. Alien Registration Number (A-Number) (if any) 7. USCIS Online Account Number (if any) 8. Application, Petition, or Request Receipt Number Information About Family Members that May Appear on Requested Records For example, provide the requested information about a spouse or children. If you need extra space to complete this section, use the space provided in Part 5. Additional Information. Family Member 1 9.a. Family Name (Last Name) 9.b. Given Name (First Name) 9.c. Middle Name 10. Relationship Family Member 2 11.a. Family Name (Last Name) 11.b. Given Name (First Name) 11.c. Middle Name 12. Relationship Parents' Names for the Subject of Record Father 13.a. Family Name (Last Name) 13.b. Given Name (First Name) 13.c. Middle Name Mother 14.a. Family Name (Last Name) 14.b. Given Name (First Name) 14.c. Middle Name 14.d. Maiden Name (if applicable) 15. Description of Records Sought. Provide a description of the records you are seeking. If you need additional space, use the space provided in Part 5. Additional Information. [Fillable field]	[Page 2] Part 3. Description of Records Requested While you are not required to respond to every Item Number in Part 3., failure to provide complete and specific information may delay processing of your request or prevent U.S. Citizenship and Immigration Services (USCIS) from locating the records or information requested. 1. State the purpose of your request. NOTE: This field is optional. However, providing this information may assist USCIS in locating the records and information needed to respond to your request. [Fillable field] Full Name of the Subject of Record 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name Other Names Used by the Subject of Record (if any) Provide all other names the Subject of Record has ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 6. Additional Information. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Full Name of the Subject of Record at Time of Entry into the United States 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name Other Information About the Subject of Record 6.a. Form I-94 Arrival-Departure Record Number 6.b. Passport or Travel Document Number 7. Alien Registration Number (A-Number) (if any) 8. USCIS Online Account Number (if any) 9. Application or Petition Receipt Number Information About Family Members that May Appear on Requested Records For example, provide the requested information about a spouse or children. If you need extra space to complete this section, use the space provided in Part 6. Additional Information. Family Member 1 10.a. Family Name (Last Name) 10.b. Given Name (First Name) 10.c. Middle Name 11. Relationship Family Member 2 12.a. Family Name (Last Name) 12.b. Given Name (First Name) 12.c. Middle Name 13. Relationship Parents' Names for the Subject of Record Father 14.a. Family Name (Last Name) 14.b. Given Name (First Name) 14.c. Middle Name [Page 3] Mother 15.a. Family Name (Last Name) 15.b. Given Name (First Name) 15.c. Middle Name 15.d. Maiden Name (if applicable) 16. Describe the records you are seeking. If you need additional space, use the space provided in Part 6. Additional Information. [Fillable field]
Pages 3-4, Part 4. Verification of Identity and Subject of Record Consent	[Page 2] Part 4. Verification of Identity and Subject of Record Consent NOTE: Complete all applicable Item Numbers. In addition, the Subject of Record MUST sign Part 4. of this request. Full Name of the Subject of Record 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name [Moved] [Page 3] Mailing Address for the Subject of Record 2.a. In Care Of Name (if any) 2.b. Street Number and Name 2.c. Apt./Ste./Flr. [Number] 2.d. City or Town 2.e. State 2.f. ZIP Code 2.g. Province 2.h. Postal Code 2.i. Country Other Information for the Subject of Record 3. Date of Birth (mm/dd/yyyy) 4. Country of Birth Contact Information for the Subject of Record Providing this information is optional. 5. Daytime Telephone Number 6. Mobile Telephone Number (if any) 7. Email Address (if any) Signature and Notarized Affidavit or Declaration of the Subject of Record Select only one box. NOTE: The Subject of Record MUST provide a signature in Item Number 8.a. Notarized Affidavit of Identity OR Item Number 8.b. Declaration Under Penalty of Perjury. If the Subject of Record is deceased, read Item Number 8.c. Deceased Subject of Record and attach proof of death. 8.a. Notarized Affidavit of Identity (Do NOT sign and date below until the notary public provides instructions to you.) By my signature, I consent to USCIS releasing the requested records to the requestor (if applicable) named in Part 2. I also consent to pay all costs incurred for search, duplication, and review of documents up to $25 (if filing this request for myself). Signature of Subject of Record Date of Signature (mm/dd/yyyy) Subscribed and sworn to before me on this day of [Fillable field] in the year [Fillable field]. Daytime Telephone Number Signature of Notary My Commission Expires on (mm/dd/yyyy) 8.b. Declaration Under Penalty of Perjury By my signature, I consent to USCIS releasing the requested records to the requestor (if applicable) named in Part 2. I also consent to pay all costs incurred for search, duplication, and review of documents up to $25 (if filing this request for myself). I certify, swear, or affirm, under penalty of perjury under the laws of the United States of America, that the information in this request is complete, true, and correct. Signature of Subject of Record Date of Signature (mm/dd/yyyy) 8.c. Deceased Subject of Record (NOTE: You MUST attach an obituary, death certificate, or other proof of death.)	[Page 3] Part 4. Verification of Identity and Subject of Record Consent Provide the information requested in Item Numbers 1.a. - 7. In addition, the Subject of Record MUST sign in Item Numbers 8.a. - 8.c. Full Name of the Subject of Record 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Other Information About the Subject of Record 2. Date of Birth (mm/dd/yyyy) 3. Country of Birth Mailing Address for the Subject of Record 4.a. In Care Of Name (if any) 4.b. Street Number and Name 4.c. Apt./Ste./Flr. [Number] 4.d. City or Town 4.e. State 4.f. ZIP Code 4.g. Province 4.h. Postal Code 4.i. Country [Moved] Contact Information for the Subject of Record NOTE: Providing this information is optional. 5. Daytime Telephone Number 6. Mobile Telephone Number (if any) 7. Email Address (if any) [Page 4] Signature of the Subject of Record Select only one box. NOTE: The Subject of Record MUST provide a signature in Item Number 8.a. OR Item Number 8.b. If the Subject of Record is deceased, select Item Number 8.c. and attach an obituary, death certificate, or other proof of death. 8.a. Notarized Affidavit of Identity IMPORTANT: Do NOT sign and date below until the notary public provides instructions to you. By my signature, I consent to USCIS releasing the requested records to the requestor (if applicable) named in Part 2. If filing this request on my own behalf, I also consent to pay all costs incurred for search, duplication, and review of documents up to $25. (See the What Is the Filing Fee section in the Form G-639 Instructions for more information.) Signature of Subject of Record Date of Signature (mm/dd/yyyy) Subscribed and sworn to before me on this day of [Fillable field] in the year [Fillable field]. Daytime Telephone Number Signature of Notary My Commission Expires on (mm/dd/yyyy) 8.b. Declaration Under Penalty of Perjury By my signature, I consent to USCIS releasing the requested records to the requestor (if applicable) named in Part 2. If filing this request on my own behalf, I also consent to pay all costs incurred for search, duplication, and review of documents up to $25. (See the What Is the Filing Fee section in the Form G-639 Instructions for more information.) I certify, swear, or affirm, under penalty of perjury under the laws of the United States of America, that the information in this request is complete, true, and correct. Signature of Subject of Record Date of Signature (mm/dd/yyyy) 8.c. Deceased Subject of Record [Deleted]
New		[Page 4] Part 5. Processing Information 1. Indicate if any of these circumstances apply to your request (Select all that apply). Circumstances in which the lack of expedited treatment could reasonably be expected to pose an imminent threat to the life or physical safety of the individual. An urgency to inform the public about an actual or alleged Federal government activity, if made by a person primarily engaged in disseminating information. The loss of substantial due process rights. A matter of widespread and exceptional media interest in which there exists possible questions about the government’s integrity which affects public confidence. Submit a certified, detailed statement regarding the basis for your request with your Form G-639. 2. Do you have a pending Immigration Court hearing date? Yes No If you answered “Yes” to Item Number 2., submit a copy of one of the following documents with your Form G-639: I-862, Notice to Appear; Form I-122, Order to Show Cause; Form I-863, Note of Referral to Immigration Judge, or submit a written notice of continuation of a future scheduled hearing before the immigration judge.
Page 4, Part 5. Additional Information	[Page 4] Part 5. Additional Information If you need extra space to provide any additional information within this request, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with your request or attach a separate sheet of paper. Type or print the name of the Subject of Record and his or her A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which the information refers; and sign and date each sheet. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. Alien Registration Number (A-Number) (if any) 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field]	[Page 5] Part 6. Additional Information If you need extra space to provide any additional information within this request, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this request or attach a separate sheet of paper. Type or print the Subject of Record’s name and his or her A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1.a. Subject of Record’s Family Name (Last Name) [Auto-populated field] 1.b. Subject of Record’s Given Name (First Name) [Auto-populated field] 1.c. Subject of Record’s Middle Name [Auto-populated field] 2. Subject of Record’s A-Number (if any) [Auto-populated field] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]

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