Privacy Act Statement

USCIS Privacy Act Statement
Form I-212

AUTHORITIES: The information requested on this benefit application, and the associated
evidence, is collected pursuant to section 212(a)(9)(A) or (C) of the Immigration and Nationality
Act, as amended INA § 101, et seq.
PURPOSE: The primary purpose for providing the requested information on this benefit form
is to obtain consent from the Secretary to reapply for admission to the United States before you
can lawfully return to the United States. The information you provide will be used to grant or
deny your benefit request.
DISCLOSURE: The information you provide, including your Social Security number, is
voluntary. However, failure to provide the requested information, and any requested evidence,
may delay a final decision or result in denial of your benefit request.
ROUTINE USES: The information you provide on this benefit application may be shared with
other federal, state, local, and foreign government agencies and authorized organizations in
accordance with approved routine uses, as described in the associated published system of
records notices [DHS-USCIS-001 Alien File (A-File) and DHS-USCIS-007 - Benefits
Information System, www.dhs.gov/privacy]. The information may also be made available, as
appropriate for law enforcement purposes or in the interest of national security.

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