G 639Dom Form – Fill Out and Use This PDF

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.

Requestor's Full Name

4.a. Family Name (Last Name)

4.b. Given Name

(First Name)

4.c. Middle Name

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)

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 Mailing Address

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

5.b. Street Number

and Name

5.c. Apt. Ste. Flr.

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

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.

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

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6.b. Passport or Travel Document Number

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

► A-

8.USCIS Online Account Number (if any)

►

9.Application or Petition Receipt Number

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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

Part 3. Description of Records Requested

(continued)

Mother

15.a. Family Name

(Last Name)

15.b. Given Name

(First Name)

15.c. Middle Name

Mailing Address for the Subject of Record

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

4.b.	Street Number
	and Name
	Apt.
4.c.		Ste.		Flr.
4.d.	City or Town

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.

4.e. State

4.g. Province

4.h. Postal Code 4.i. Country

4.f. ZIP Code

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 for the Subject of Record

2.Date of Birth (mm/dd/yyyy)

3.Country of Birth

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)

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

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		in the year			.

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

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.

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)

5.a. Page Number 5.b. Part Number 5.c. Item Number

5.d.

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

1.c. Subject of Record's Middle Name

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

► A-

3.a. Page Number 3.b. Part Number 3.c. Item Number

3.d.

4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

6.a. Page Number 6.b. Part Number 6.c. Item Number

6.d.

7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.