Form G-639 Freedom of Information/Privacy Act Request

Freedom of Information/Privacy Act Request
Department of Homeland Security
U.S. Citizenship and Immigration Services
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.

USCIS
Form G-639
OMB No. 1615-0102
Expires 04/30/2020

Requestor's Full Name

DRAFT
NOT FOR
PRODUCTION
06/19/2019

► START HERE - Type or print in black ink.

4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)

4.c. Middle Name

Part 1. Type of Request

Requestor's Mailing Address

Select only one box.

5.a. In Care Of Name (if any)

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)

5.b. Street Number
and Name

5.c.

Part 2. Requestor Information
1.

Are you the Subject of Record for this request?
Yes

(USPS ZIP Code Lookup)

Apt.

Ste.

Flr.

5.d. City or Town

5.e. State

5.f.

ZIP Code

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.

5.g. Province

5.h. Postal Code
5.i.

Country

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 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)

Form G-639 04/17/17

Page 1 of 5

Part 3. Description of Records Requested

Other Information About the Subject of Record

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.

6.a. Form I-94 Arrival-Departure Record Number

1.

►
6.b. Passport or Travel Document Number

DRAFT
NOT FOR
PRODUCTION
06/19/2019

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.

7.

Alien Registration Number (A-Number) (if any)
► A-

8.

USCIS Online Account Number (if any)
►

9.

Application or Petition Receipt Number
►

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)

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

4.c. Middle Name

Parents' Names for the Subject of Record
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

Form G-639 04/17/17

Father
14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)
14.c. Middle Name

Page 2 of 5

Part 3. Description of Records Requested
(continued)

Mailing Address for the Subject of Record
4.a. In Care Of Name (if any)

Mother
15.a. Family Name
(Last Name)
15.b. Given Name
(First Name)

DRAFT
NOT FOR
PRODUCTION
06/19/2019

15.c. Middle Name

15.d. Maiden Name (if applicable)

16.

4.b. Street Number
and Name

Describe the records you are seeking. If you need
additional space, use the space provided in Part 6.
Additional Information.

4.c.

Apt.

Ste.

Flr.

4.d. City or Town
4.e. State

4.f.

ZIP Code

4.g. Province

4.h. Postal Code
4.i.

Country

Contact Information for the Subject of Record

NOTE: Providing this information is optional.

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.

5.

Daytime Telephone Number

6.

Mobile Telephone Number (if any)

7.

Email Address (if any)

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 for the Subject of Record
2.

Date of Birth (mm/dd/yyyy)

3.

Country of Birth

Form G-639 04/17/17

Page 3 of 5

8.b.

Part 4. Verification of Identity and Subject of
Record Consent (continued)

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 the Subject of Record
Select only one box.

DRAFT
NOT FOR
PRODUCTION
06/19/2019

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.

Declaration Under Penalty of Perjury

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.

Notarized Affidavit of Identity

IMPORTANT: Do NOT sign and date below until
the notary public provides instructions to you.

Signature of Subject of Record

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.)

Date of Signature (mm/dd/yyyy)

8.c.

Part 5. Processing Information

1.

Signature of Subject of Record

Subscribed and sworn to before me on this
in the year

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.

Date of Signature (mm/dd/yyyy)

day of

Deceased Subject of Record

An urgency to inform the public about an actual or
alleged Federal government activity, if made by a
person primarily engaged in disseminating
information.

.

Daytime Telephone Number

The loss of substantial due process rights.

Signature of Notary

A matter of widespread and exceptional media
interest in which there exists possible questions about
the government's integrity which affects public
confidence.

My Commission Expires on (mm/dd/yyyy)

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.

Form G-639 04/17/17

Page 4 of 5

5.a. Page Number

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.

5.b. Part Number

5.c. Item Number

5.d.

DRAFT
NOT FOR
PRODUCTION
06/19/2019

1.a. Subject of Record's Family Name (Last Name)

1.b. Subject of Record's Given Name (First Name)

1.c. Subject of Record's Middle Name

6.a. Page Number

2.

Subject of Record's A-Number (if any)
► A-

3.a. Page Number

3.d.

3.b. Part Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

3.c. Item Number

7.a. Page Number

7.d.
4.a. Page Number

4.b. Part Number

4.c. Item Number

4.d.

Form G-639 04/17/17

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