U.S. Customs and Border Protection  
1300 Pennsylvania Avenue, NW
Attn: Mint Annex Building, FOIA Division
Washington, D.C. 20229

REQUEST FOR RECORDS/PRIVACY ACT RELEASE FORM 

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

___________________________________________________________________________________________________


Consent to Release Information (Complete if name is different from requester)

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