Requests received
without a letter of explanation will not be processed.
(Please Print)
The Identity Project notes that a request for personal records contained in a System of
Records, as defined by the Privacy Act of 1974, does not require an explanation
as to the reason for the record request, and that the records it obtained from
the ATS System of Records was done by the requester without giving an
explanation as to why they were requested and by providing only his / her full
name, current address, date of birth, and place of birth.
Family Name Given Name Middle Name
___________________________________________________________________________________________________
Address (Street Number and Name) Apt Number
___________________________________________________________________________________________________
City State Zip Code
___________________________________________________________________________________________________
Date of Birth Country of Birth Other names used; if any
___________________________________________________________________________________________________
Name at time of entry into the U.S. Date of Entry into the U.S. Port of Entry into the U.S.
___________________________________________________________________________________________________
Passport Number Alien Registration Number Petition or Claim Receipt
___________________________________________________________________________________________________
I-94 Admission Number Naturalization Certificate Number Naturalization Date
___________________________________________________________________________________________________
I understand that knowingly
or willfully seeking or obtaining access to records and/or information about
another person under false pretenses is punishable by a fine up to $5,000. I also understand that any applicable
fees must be paid by me. I request
that any located and disclosable CBP records and/or information be forwarded
to:
Name of Requester (Last, First and Middle Name)
___________________________________________________________________________________________________
Address (Street Number and Name) Apt Number
___________________________________________________________________________________________________
City State Zip Code
___________________________________________________________________________________________________
I declare (or certify,
verify, or state) under penalty of perjury under the laws of the United States
of America that the foregoing is true and correct.
___________________________________________________________________________________
Signature
Date
Note: The
signature on this request is not required to be notarized; however, severe
penalties may apply for false identification. Revised January, 2006